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Excision of mass right small finger

  1. #1
    Default Excision of mass right small finger
    Medical Coding Books
    Here is operative report and tell me what is missing ?

    Dx - Mass, right palm and base of small finger
    OPERATION :Excision of mass, right small finger base and palm

    Procedure in detail :
    .After informed consent was obtained the patient was bought to operating room and placed in a supine position on operating table. Bier anesthesia was induced in the right arm. The right palm was prepped draped in sterile fashion. An incision was carried out in zigzag fashion in the base of the small finger, dissection taken down through the subcutaneous tissue. The digital neurovascular bundle and artery were reteacted and the white -appearing mass was seen attached to thr radial side of the base of the proximal phalanx. This was resected free wwith sharp dissection, some milky material leaked out of this. It was sent for culture and the specimen was sent to pathlogy. The wound was irrigated, injected with 0.5% Marcine and then tourniquet was deflated at 25 minutes. Hemostasis was obtained with electrocautery. It was closed with 4-0 nylon, was placed in sterile soft dressing.

    Path report came back as 709.3 calcinosis cutis-

    Now I want to code it as 26115, but it says less than 1.5 cm
    no size is on operative report, should doc dictate size , or am I using the wrong code all together?

  2. #2
    Milwaukee WI
    Default Size of mass needed
    The sizes of cysts, tumors, etc were added to many revised and new codes in 2010. Most surgeons just aren't used to having to include this information.

    By all means ask the physician to dictate and addendum stipulating the size of the mass. And let all your surgeons know of these changes to CPT for 2010.

    F Tessa Bartels, CPC, CEMC

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