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Method of a removal and reimbursement

  1. Default Method of a removal and reimbursement
    Medical Coding Books
    Hi everyone,

    I have a question, I have 2 providers that do cyst removals and both of them do it a different way, I'll explain...

    Provider one: Makes an incision across the top of the cyst, opens the pocket and scrapes out the cyst with scissors and snips it out and closes the wound with a repair. example: 1.0cm x 1.5cm no margins included so the selected code would be 11401 CPT of the arm. This doctor states that margins are never included to remove a cyst.

    Provider two: Cuts around the cyst, included margins, example: 1.0cm x 1.5cm with 0.5cm margins so the total removal would be 2.5cm post op. So the code selected would be 11403 CPT of the arm. This doctor has always done it this way...

    One gets a higher reimbursment than the other, who is right who is wrong? Or can they select the method of their choosing and continue to get payed based on their method of choice?



  2. #2
    In my opionion neither is wrong...the providers are simply using different techniques. You are correct in coding to the actual excision size. Think of it as the provider that performs the procedure without margins is performing a less invasive procedure. A comparison example would be laparoscopic chole versus open chole. The open procedure is a more invasive technique and therefore paid at a higher fee schedule allowance even though the end result is the same. It would not be appropriate for your surgeon to change his technique simply to increase reimbursement if he/she feels that his current technique results in safe and effective removal of the cyst.

    Hope this helps.

    Julie, CPC

  3. #3
    Milwaukee WI
    Default Excise cyst vs Excise lesion
    Removal of a cyst is not the same thing as excising a lesion. Are you sure you shouldn't be using a code from the musculoskeletal section .. for example 25075. Or if it is a pilondal cyst, 11770-11772.

    F Tessa Bartels, CPC, CEMC

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