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Excision Tumor codes

  1. #1
    Default Excision Tumor codes
    Clearnace Sale
    Does the path have to come back as a tumor to use "Excision,tumor" codes? I've seen other coders suggest using the musculoskeletal excision codes for cysts, etc. but I thought the diag had to match the description of the code. For example, a pt had a low axillary mass located in subcutaneous tissue that came back as "benign breast tissue with nodular pseudoangiomatous stromal hyperplasia". The mass was located in the subcu so I'm wondering if I should use 11403 or 21555. Any suggestions?
    Sue Vermette, CPC, CPMA

  2. #2
    Did you look at the 19120 code - Hope this helps
    Deb, CPC

  3. #3
    Default Here's what's documented
    Thanks for the response! The doc did pick 19120 and I reviewed the code versus what was documented and didn't think I could support a breast code. What do you think? BTW, she also did a biopsy of a lymph node.

    ...incision was made in the axilla. Dissection was carried down into the axillary fascia. The lymph node was immediately palpable. It was excised using cautery. I then tunnelled inferior to the incision to the mass, which was very mobile. It was removed by circumferential excision using cautery. The architecture appeared to be consistent with a fibroadenoma but abnormal lymph node would have the same appearance. A couple of small bleeding points in the axilla were controlled with cautery. Incision was then closed with running subcuticular suture of 4-0 Vicryl.

    OPERATIVE FINDINGS: Enlarged lymph node...She had a rubbery mass in the low axilla, approximately 3 cm away. This was bivalved in the operating room and looks to be consistent with a possible axillary fibroadenoma.

    She doesn't use the word "breast" in her report at all but would that matter if we used code 19120? Which do you think would be the best code to use?
    Sue Vermette, CPC, CPMA

  4. #4
    Default Excision tumor codes
    Not sure about that. Maybe you could use the 38500 code.
    Biopsy or excision of lymph node(s); open -superficial ??
    Deb, CPC

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