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Excision Abdominal Mass

  1. #1
    Default Excision Abdominal Mass
    Medical Coding Books
    any suggestions on coding of excision of lower abdominal mass? should i use the 1140x codes? the doctor doesnt specify the excised diameter on the op report!

  2. #2
    Albany, New York
    Do you have a pathology report to refer to?

    I am asking not only because those reports usually indicate dimensions, but also would indicate if the lesion was malignant. In that case, you would be looking at the 1160X code range.
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    ...the op report stated that it was a benign cyst so there is no need for path report since dx is already just doesnt say how much was excised!

    i guess i'm gonna have to request a copy of the path report...thx tho!
    Last edited by mad_one80; 01-09-2009 at 05:12 AM.

  4. #4
    Milwaukee WI
    Default Educate doc - ask for amendment
    I'd educate the doctor about the need for specifying size BEFORE excision. Why? Because tissues will shrink when they're sent to pathology. So you may have a smaller diameter on the path report that the measurement (if taken) prior to surgery.

    I would ask the doctor to dictate an amendment specifying the size of the cyst.

    Secondly .. you say it was "an abdominal mass" and that it was "a benign cyst" ... wouldn't you be using 49203-49205 (depending on size of mass)?

    I still have to remind my surgeons every once in a while about the need for the size. Even though the 4920X codes have been in effect since last January.

    F Tessa Bartels, CPC, CEMC

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