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Help! Coding this Op report.

  1. #1
    Default Help! Coding this Op report.
    Medical Coding Books
    Operation Performed: Left inguinal exploration and excision of lipoma.

    A transverse inguinal incision was then made. This was carried to the subcutaneous tissues. I then placed one finger into the inguinal area via the scrotum. I pushed up the mass which had been quite tender and incised over that. It actually turned out to be a lipoma which was excised. Hemostasis was ensured using cautery.

    I just need a code for the left inguinal exploration.

    Any suggestions! Thanks.

  2. #2
    Milwaukee WI
    Default Excision only
    NOT my area of expertise, BUT ...

    If this is all the op report, I'd code the excision of lipoma ONLY.

    F Tessa Bartels, CPC, CEMC

  3. Default inguinal exploration
    see cpt code 54550 for exploration and 54512 for excision of lipoma.

  4. #4
    The op note is a little unclear as to where the lipoma excision was made. If the lipoma is located on the spermatic cord you could consider 55520.

  5. #5
    Default Help! Coding this Operative Report
    Code 54560 is for undescended testis and that wasn't the reason for the exploration. I have a code for the excision of the Lipoma which was located anterior to the spermatic cord and distal to the external ring. I am just really confused on the Left Inguinal Exploration. I am leaning towards just coding for the excision of the Lipoma. Thanks so much for your comments and anything further would be appreciated.

  6. #6
    I don't see the exploratory part of the op report in your post, so it that's the entire report I'd just code the lipoma excision.

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