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Second opinion.... Back mass excision

  1. #1
    Default Second opinion.... Back mass excision
    Medical Coding Books
    Procedure: The patient was brought to the operating room and placed in the
    supine position. With appropriate monitoring, she was induced with general
    anesthesia without complication. She was then turned on her side and the area
    was painted with Betadine and draped in a sterile fashion. An elliptical incision
    was made encompassing some of the hairs over the mass and then
    electrocautery was used to dissect around the mass. The mass was excised and
    sent in its entirety to pathology for evaluation. 3-0 Vicryl was used to
    reapproximate the subcutaneous tissue and 4-0 Vicryl was used to
    reapproximate the skin in a subcuticular manner. Steri-strips and a dry sterile
    dressing were applied.

    11400
    12031 for double layer closure??

    DX782.2

  2. #2
    Default
    From reading your note I am pointed in the direction of CPT code 21930 - Excision, tumor, soft tissue of back or flank. Using this code would account for the layered closure since it is specifically included in the code description.

    I hope this helps.
    Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC
    AAPC CEU Vendor Department Manager

  3. Default
    I would look to the pathology report for a diagnosis. I guess my biggest issue with this OP note is that it doesn't state how deep the surgeon went. I don't think there's enough information in this note to justify the excision of a soft tissue mass.

    ~L
    CPC, CGSC, COSC

  4. #4
    Default
    An elliptical incision
    was made encompassing some of the hairs over the mass and then
    electrocautery was used to dissect around the mass. The mass was excised and
    sent in its entirety to pathology for evaluation. 3-0 Vicryl was used to
    reapproximate the subcutaneous tissue and 4-0 Vicryl was used to
    reapproximate the skin in a subcuticular manner. Steri-strips and a dry sterile

    This is all Ive got... No path report either....

  5. #5
    Location
    Dickson, TN
    Posts
    21
    Default
    We never submit anything that is excised without the path report. I would hold until the path comes in.

  6. #6
    Default BacK Mass Excision
    I concur with awaiting for the pathology report .
    Deborah, CPC

  7. #7
    Default
    While you are waiting for the path report, I would speak to the provider and ask how deep they went to get the specimen. However you know that they at least went into the subque tissue otherwise you wouldn't be able to do a layered closure. But just for confirmation it wouldn't hurt to verify.
    Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC
    AAPC CEU Vendor Department Manager

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