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Excision coding

  1. #1
    Default Excision coding
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    I have a mass excision in the subcut of the abdominal wall. Is this simply an excision case or more? I may be reading too much into it, being a Friday and all. I got 11406, 12032.

    Postop Dx: subcutaneous endometriotic nodule

    "epinepherine was infiltrated into the skin and subcut. A 5-cm skin incision was made over the nodule and carried down to the nodule. Additional local was injected in the deeper tissues to achieve total patient analgesia. Using sharp dissection, the nodule was remove. It transected on the Mayo stand with findings as noted above. The incision was irrigated and hemostasis was achieved with electrocautery. Incision was closed deeply with 2 running layrs of 3-0 Vicryl, then was reapproximated with a 4-0 monocryl......"

  2. #2
    Albany, New York
    Based on your documentation, I agree with your code choices.
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Thanks Karen! I was having a really long week Anyway, They put endometriotic nodule as the Dx and the closet I could come was abdominal mass, 789.33, and 3M doesn't seem to agree with that code choice. The only other code I could find was where the physician wrote endometriosis, which I also coded, and that didn't do anything to help. Do you think there is another dx that might be more appropriate for this procedure? I can't believe that I am having such a hard time with such a simple chart, but I am a bit of a perfectionist so I just can't let it

  4. #4
    Albany, New York
    I encounter the same situation sometimes with 3M.
    Then I'll check my Surgical Cross-Coder and the dx code I chose will be listed for the CPT I assigned.
    Just curious, did the Path report concur with the Post-Op dx listed on your OP note?
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
    I wish I had a cross-coder here for us to use! They are not to keen about adding anything that they consider "extras" around here. We even have to buy our own books here and I work at a hospital for crying out loud. Anyway, the path did come back with endometriosis so that helped confirm it for me. Do you agree with those codes?

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