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20205 vs. 27614

  1. Question 20205 vs. 27614
    Medical Coding Books
    Fellow coder and I are stumped. After reviewing definations and googling on the internet we are still stuck between these 2 CPTs. I am posting the actual procedure documentation. Please review and provide any suggestions, comments and/or links. Any and all is welcome. Thanks!!

    Pre-Op diagnosis : Unspecified muscle generalized pain
    Post-Op diagnosis : same
    Location and size : right leg
    Anesthesia : 1% plain Lidocaine
    Pre-Op : Informed consent was reviewed with the patient, treatment alternatives were discussed, consequences of refusal of treatment discussed, risks and benefits discussed including but not limited to scarring, infection, bleeding, recurrence, need for further treatment., The patient's questions were answered to his/her satisfaction., Signed consent in chart
    Procedure : patient placed in a comfortable position to allow the excision of the mass. Area sterily prepped and draped in the usual fashion. Longitudinal Skin incision done with a #15 blade and muscular fascia of gastrocnemius muscle visualized and open longitudinally. A 2.5 cm longitudinal piece of muscle was individualized and excised between clamps. Borders of the muscle ligated with catgut chromic 2-0. Hemostasis done with pressure, then catgut chromic #3-0 for the bleeding vessels.
    Closure : Fascia closed with 3-0 chromic catgut, interrupted fashion. Skin closed with nylon 3-0 interrupted fashion. Patient tolerated the procedure well and was discharged home in stable condition.

  2. Default
    I would go with 27614 because it is specific to the area operated on in this case.

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