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  1. #1
    Default wIDE lOCAL iNCISION
    Medical Coding Books
    How would you code this?
    Preoperative Diagnosis: B-cell lymphoma back x2.
    Postoperative Diagnosis:B-cell lymphoma back x2.
    Operation: Wide local excision of B-cell lymphoma on back.
    Description of Operation:
    The patient was brought to the operating room and placed on the table in a supine position. Under adequate IV sedation, he was prepped and draped around his back in usual sterile fashion. An ellipse of tissue was taken around each area, deepened to the patient's fascia to subcutaneous tissue with margins around these areas. Once this was done, they were closed in layers with absorbable suture followed by reapproximation of skin with nonabsorbable sutures. Bandages were applied. The patient was awakened. This was done so in both areas. The patient was awakened and transported to his room.

    Would you use musculoskeletal system-cpt code 21930 or would you use Integumentary System?
    Thanks, Trent

  2. #2
    The integumentary system codes for excision are full thickness, generally using no subcutaneous tissue or very little. Also for these codes you need the sizes, which those are not documented.

    The documentation states the excision went to the fascia, which is connective tissue or soft tissue, and subcutaneous tissue. Therefore, I would recommend 21930 and 21930-59 (two different excisions)

  3. #3
    thank you

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