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Help-Coding groin mass

  1. #1
    Default Help-Coding groin mass
    Medical Coding Books
    6 cm incision of the lt groin mass - Op note as follows:
    6 cm eliptical inc.made around the mass in the lt groin.
    Sharp dissection was used to dissect the mass free. vessels suture ligated using 2-0 Dexon suture ligature.Mass sent fresh for Histo. Subcutaneous tissues were closed using 2-0 Dexon and the skin closed with interrupted 3-0 vertical masstree nylon suture. Path:Acute Abscess, Skin and underlying soft tissue from the lt.groin Please help with coding - Im still new! Thanks Debbie CPC-A

  2. #2
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    I'd be looking at the "excision - benign lesions" 11400 - 11406 codes, for the CPT code and 789.3x codes for the mass. (based on the info you've given)
    Is that correct though, 6 cm? or is it .6cm?
    Donna, CPC, CPC-H

  3. #3
    Smile panam
    Hi there , I am new to coding and posting too. I'd like to take a shot
    at helping though.
    The ICD-9 code is 682.2 [abscess,acute, groin].This is from the path-
    logy report.
    The CPT code is 11406 ,Excision -Benign Lesions. This is because the
    size of the incision to remove the abscess is over 4.0cm. Hope this
    helps.
    panam

  4. #4
    Default Thank you
    Thanks so much for all your help! I was just confused because it stated incision instead of excision.
    Debbie CPC-A

  5. #5
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
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    Hi Debbie,

    You may need to double check with your surgeon on this. It appears that, based on the closure alone (he indicates closure of the sub-q layer) , that he went through the subcutaneous tissues for the excision of this mass, however he never states the depth of the incision.

    If it truly went through the sub-q layer then you will need to look further than the "excision of benign lesion" codes.

    I would also wait on your diagnosis until the path/Hist report comes back for confirmation of what exactly the mass was.

    My two cents
    Mary

  6. #6
    Default
    Quote Originally Posted by panam View Post
    Hi there , I am new to coding and posting too. I'd like to take a shot
    at helping though.
    The ICD-9 code is 682.2 [abscess,acute, groin].This is from the path-
    logy report.
    The CPT code is 11406 ,Excision -Benign Lesions. This is because the
    size of the incision to remove the abscess is over 4.0cm. Hope this
    helps.
    I agree that the dx should be 682.2 and I also agree with the 11406 excision code. Did the surgeon do a repair at all?
    Chrissy, CPC

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