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Lesion Removal

  1. #1
    Default Lesion Removal
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    Lesion Removal


    This may sound silly but I read the report below and came up with 11443 but my provider states it should be 67412 because he went into the muscle. Please let me know who is right.

    DX: Dermal inclusional Cyst. (per pathology report)

    After the administration of anesthesia, the patient was
    prepped and draped aseptically. Preoperative antibiotics were
    administered. Incision was designed and executed after injecting Marcaine
    with epinephrine. Incision was designed right next to the brow. Incision
    was taken through the skin, subcutaneous tissue, and then through the
    musculature. The mass was then encountered. Sharp and blunt dissection
    was then performed to isolate the mass. We then went after the bottom of
    it. It significantly indented the bone underneath. We then removed the
    mass in its entirety. There was no full-thickness penetration. The wound
    was copiously irrigated. It was a dermoid. The closure was then performed
    with interrupted Vicryls in the muscle and dermis followed by absorbable
    sutures in skin. Antibiotic ointment was applied. The patient's care was
    turned over to Anesthesia. Lesion was 2.5 cm

  2. #2
    Albany, New York

    I don't see the word "orbit" in the report (??)
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Columbia, MO
    67412 states the lesion is in the orbit and the approach is subciliary, frontal (thru the lid), or transconjunctival. I have not found a better match than 11443 and I was certain that there would be! You could always append a 22 if you really feel the documentation supports it.
    Last edited by mitchellde; 06-10-2009 at 04:00 PM. Reason: gramatical

  4. Default
    Hello, I am a little late with a response, but I definitely agree with everyone that CPT 11443 is correct, but don't forget that a layered closure was performed (The closure was then performed with interrupted Vicryls in the muscle and dermis followed by absorbable sutures in skin), therefore, CPT 12051 should be billed as well.

    CT ENT

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