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Excision of epidermal inclusion cyst on breast

  1. #1
    Default Excision of epidermal inclusion cyst on breast
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    Doc did an excision of cyst on breast
    Local anesthesia was appllied to breast. A small 2cm inicsion was made over the top of the palable cyst. Dissection was carried out wiyh electrocautery and the cyst was excised. Hemostasis was obtained, and the skin was closed in two layers. The specimem was sent to Pathology.

    Now do I AS 19120 or 11403 with a layered closure. ?Doc office says use 11403, but no size is reported, any suggestions ?thanks

  2. #2
    Milwaukee WI
    Default 114xx
    I would definitely code this from the 114xx section as it is an epidermal cyst, not a breast tissue cyst.

    However the physician MUST dictate the dimension in order to be able to code this accurately. This can be done as an addendum if the original operative note is already signed. It's NOT going to be 11403 in any case, because the incision is 2 cm long, so the cyst cannot be 2.1-3.0 cm.

    Don't forget to code the layered closure of that 2 cm incision.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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