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Incisinal biopsy axillary mass

  1. #1
    Default Incisinal biopsy axillary mass
    Medical Coding Books
    Patient ghad an incisional biopy of axillary mass as well as right arm bass ,
    . My question is would it be cpt code 240654- and axillary mass 21555 , the booking was 11606 for axillary, not sure this would be good, PATH REPORT CAME BACK AS 196.9 FOR AXILLARY AND 195.4 FOR ARM

  2. #2
    Albany, New York
    Would it be possible to provide description of those procedures documented in the OP report?
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Default Procedure
    DIAGNOSIS : Sacroma rt upper extremity, metastatic
    PROCEDURE : Incisional biopsy axillary mass , as well as rt arm mass

    An incision was made on the previous incision site after the skin and sub tissue was infiltrated with 0.25% marcaine deep into the mass , which was debulked all the way to patient lower axilla before some major vessels were encountred precluding tital resection. Once this was done it was sent to pathlogy for analysis. Hemostasis was achieved with electrocautery. The wound was closrd in layers with absorbable suture. Steri-Strips were applied.
    The patient on his rt proimal arm had another mass that could be appreciated that was sort of deep on rt arm. This was deepened to the area concern, , which was circumferentially dissected. However, this was involving major blood vessels of ther brachial artery and the veins, as well as the radial nerve to a certain extent. Because for this major vascular involvement, I thought that the patient was not a candidate for total resection of this mass as well. This was debulked aall the way down to the vessels, removed, and sent to pathlogy. Hemostasis was obtained with electrocautry. The wound was then closed in layerwith absorable sutures.

    195.4 FOR UPPER ARM-

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