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incisional biopsy 5 cm done on at the occipital scalp

  1. Default incisional biopsy 5 cm done on at the occipital scalp
    Medical Coding Books
    a patient presented with a lesion, 5 cm soft subcutaneous mass. an incisional biopsy under local anesthesia was performed. in the cpt expert for general surgery/gastroenterology the plain english description matched very closely to the notes the physician had written. i work from home and discussed the case over the phone with the surgeon. he however only had the regular cpt book to look at and did not agree with cpt code 21550. even the commonly used diagnostic codes indicated a mass of the scalp as acceptable. how would you have coded?

  2. #2
    Default
    I probably would have coded from the integumentary
    section; although without the operative report kind of hard
    to say and also would need to see the pathology report
    this is just my opinon. Deb,CPC

  3. Default
    I also feel it should be from Surgery, Integumentary system. But wherein from this section?

    Before Path report, our surgery code code should fall into Excision Benign Lesions as pe rthe size of the lesion-SCALP: 11426 excised diameter over 4.0cms.
    If closure was a simple one, it includes with that. If the closure was intermediate or complex, it should be reported separately from 12031-12057 or complex closure 13100-13153) as an addtional code.
    Do I make some sense?

  4. #4
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    Was this a biopsy or an excision? An excision is a removal of the entire visible mass, a biopsy is a removal of only a piece of the mass.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    This is a smart question. I thought of asking this ; but I did not go for a second round. Moreover, the site and the more superficiality of the mass,tempted me to think it would have been easier for the surgeon to get rid of the subcutaneous mass rathe rthan going for incisional biopsy (may be needle biopsy would do or a frozen section). But he is the bass and his documentations are our authority. What he did is to be coded. Diagnosis code will throw some light on this I think
    But I am sorry, he did it under local so your question is right to confirm whether was it an incisional biopsy or not
    Last edited by preserene; 08-14-2010 at 03:23 PM.

  6. #6
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    Quote Originally Posted by preserene View Post
    I also feel it should be from Surgery, Integumentary system. But wherein from this section?

    Before Path report, our surgery code code should fall into Excision Benign Lesions as pe rthe size of the lesion-SCALP: 11426 excised diameter over 4.0cms.
    If closure was a simple one, it includes with that. If the closure was intermediate or complex, it should be reported separately from 12031-12057 or complex closure 13100-13153) as an addtional code.
    Do I make some sense?
    The problem is if this were an excision you cannot code prior to path. To code a benign excision you must know that it is benign, this is not a fall back position. The AMA has stated that excisions are to be help until the path has been returned. That is why I wanted to know if it was truely an excision or a biopsy by definition. To know whether to code from the integumentary or musculskeletal section, an op report would be helpful. A surgeon I worked with said to look at what is being excisied, if you are excising an anomoly of the skin or dermis then it is integumentary, however if the problem can be felt as in a mass or nodule below the skin and you had to originate your excision in the subcutaneous layer then it is musculoskeletal.
    I think first it is important to know what was truely preformed.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    it was an incisional biopsy just as the plain english description stated in the coding and billing for general surgery. the plain english description states soft tissue biopsy of the neck or thorax is performed. soft tissues include muscles, tendons,fat,blood vessels,lymph vessels,nerves, and tissues surronding the joints. local,regional, or general ansthesia or conscious sedation is administerd. an incision is made and tissue is dissected down to the mass or lesion taking care to protect blood vessels and nerves. a tissue sample is taken. the incision is closed.

    the doctors notes followed that almost verbatum that is why i thought it should be this code. the location of it being on the occipital scalp is what i was finding to be tricky

  8. #8
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    I am confused, you want to use a code that specifies the neck and thorax as the location for a procedure performed on the scalp? I will need to see the surgery note to come up with a code but on this I agree with your physician that the 21550 is incorrect.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default
    he used a diagnosis of 172.4 which per the coding and billing for general surgery expert is an acceptable diagnosis. that is why i love this cpt book. it gives the plain english descriptions, the commonly used icd 9 codes, rvu's and cci edits

  10. #10
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    174.2 is a dx code for malignant melanoma of scalp and neck, so it would support the 21550. Bottom line is that is not the procedure he performed. You must code the procedure documented.

    Debra A. Mitchell, MSPH, CPC-H

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