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What's wrong with buttock mass ?

  1. #1
    Default What's wrong with buttock mass ?
    Medical Coding Books
    Looking in the index in cpt code book there isnt really any specfic code for an excisional biopsy of buttock mass.

    Here is the operative report :Excisional biopsy of buttock mass, presumed epidermal inclusion cyst

    The patient was bought into the operating room and placed on the operating table in lateral decubitus position. The right buttock was prepped and draped in a sterile fashion. Then 9 cc of 1% lidocaine with epinephrine was injected for local anesthesia. An elliptical incision was made over the mass to excise it with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. The subcutaneous tissue was closed with interrupted 3-o Vicryl, and 4-o nylon horizontal mattress sutures were used to close the skin . A sterile dressings was applied

    Now , its an epidermal cyst which i would want to code 1140x, but doc did not state the size of cyst , or do i code it from musculoskeltal system ?
    any suggestions? please reply

  2. #2
    I agree that 1140x is the right code set to use.. but you don't have enough documentation to choose a proper code. I think your physician needs some training in how to document this procedure properly. I don't see how there is any code from the musculoskelatal system that would apply.

    Maybe you can get your doctor to make an addendum to the op note stating the size of the lesion...
    Walker Bachman, CPC, CPPM

  3. #3
    Thanks walker 22,

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