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Need help w/axillary mass

  1. Default Need help w/axillary mass
    Medical Coding Books
    My doc did a procedure where he excised a mass on the right axillary. I cannot find a cpt code that makes sense. Please help! Notes are below:

    PROCEDURES: Right axillary mass excision.

    INDICATION FOR PROCEDURE: female with what appears to be a right axillary mass, which has been bothering her, which she wants removed. It was decided that an excision with tissue sent to pathology for evaluation would be undertaken in the operating theater. Informed consent was obtained and all questions were answered according to patient's satisfaction.

    DESCRIPTION OF PROCEDURE IN DETAIL: Patient was brought back to the operating room, placed on the OR table in a supine position. _____ General anesthesia was administered. Patient was then prepped and draped in the usual sterile fashion for the right axilla. Time-out was performed. The large right axillary mass was then sharply incised in a circumferential manner at its base. Then electro Bovie cautery was used in order to remove this mass in its entirety. The removed specimen measured 12 x 9 x 3.5 cm. This will be sent to pathology for evaluation as a permanent section. After the mass was excised, the wound was thoroughly irrigated and the wound bed was inspected for hemostasis. Hemostasis was achieved. We then used a 2-layer closure by running _____ Vicryl in the deep layer and then a 4-0 Monocryl in the dermal layer. The area was then dressed with Dermabond. The patient was then extubated and taken to the PACU in stable condition.
    Last edited by knperry; 10-03-2014 at 10:10 AM.

  2. #2
    Daytona Beach, FL
    What kind of mass was this, such as lipoma or sebaceous cyst? Did you get a path report? The code probably would be 21552, however I would not be sure until I know what the mass was. Also, you should re-edit your question as you have not taken out patient information!!
    Jodi Dibble, CPC

  3. Default
    Oh man, thank you! Its fibrosclerosis.

  4. #4
    Daytona Beach, FL
    Oh man, thank you! Its fibrosclerosis
    No problem! I would use code 21552 then for that diagnosis. If it had been a something like a sebaceous cyst, then I would have then gone for a code for a skin lesion removal.
    Jodi Dibble, CPC

  5. Smile
    Thank you so much

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