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cyst removal

  1. #1
    Chesapeake City Chapter
    Default cyst removal
    Medical Coding Books
    If a cyst was excised to the level of the subcutaneous tissue do i code from the integumentary or Musculoskeltal?

    Op report:

    with a #15 scalpel blade the cyst was excised down to the level of the subcu tissues and sent for permanent pathology. Bleeding was controlled w/ electrocautery. Closure was performed using 4-0 Monocryl suture in inverting fashion for the dermis and 5-0 nylon suture for the skin. A 1/2 inch Steristrip was applied. The patient will follow up in one week.

    Path report:

    the specimen is submitted in formalin labeled "cyst left lateral thight" and consists of a discoid shaped cystic structure which is covered by a thin membrane and measures 1.6 cm in diameter and 0.8 cm in thickness. It is attached to an elongated ellipse of brown skin measuring 2.0x0.4cm. the center of the ellipse of skin exhibits a rounded depression measureing 0.2 cm in diameter. On sectionin, the cyst is filled w/ brown grumous material. A representative section is submitted in one cassette.

    I'm leaning towards integumentary but i don't have any measurements on the op report

  2. Default
    I would also go w/ the integumentary section. I would check with the doctor on the measurements. I don't use size off path report.

  3. #3
    I would go with 11400 - . This is like a lipoma, and they aren't coded to the musculoskeletal section unless they go deep into the subcutaneous,subfascial tissue. Your report doesn't sound that deep.
    I feel for you about the absence of size of the lesion. Our doctors never want to give me the size either.

  4. #4
    Chesapeake City Chapter
    I think that lack of size of lesion and margins is a problem with a lot of dr's and facilities. Oh well. Thanks for the help

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