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clavicular mass ?

  1. #1
    Default clavicular mass ?
    Medical Coding Books
    could not find a clavicular mass in cpt book. Shold i just code this an intergumentary system-11400 series and with a repair code ?

    OPERATION: Excision of left clavicular mass clinically a lipoma around 3 to 5 cm.
    STOPERATIVE DIAGNOSIS: Left clavicular mass.


    After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, and underwent general anesthesia with laryngeal mask. The area of the left shoulder and the left clavicular area was prepped and draped in the normal fashion. The patient had been examined by me in the preoperative holding area and identified prior to this. Prior to the use of Bovie cauterization, the patient was prepped with DuraPrep solution, and about three to five minutes were waited prior to using Bovie. An incision was made directly over the mass on the inferior part of the clavicle. Dissection was carried down to skin and subcutaneous tissue. What appeared to be a clinical lipoma was removed. It was around 3 to 5 cm. Excellent hemostatic was noted to be obtained. The wound was closed with 3-0 Vicryl for the subdermal layers and 4-0 Vicryl in a subcuticular fashion. Steri-Strips and a sterile dressing were placed.

    The patient tolerated the procedure and was transferred to the recovery room in stable condition.
    path report came back as a lipoma
    _____________________________________ ______________

  2. Default
    The operative note indicates it is not of osteous origin but it is from the integumentary invovling Skin and Subcuteneous from the infraclavicular region and Lipoma, a benign neoplasm.
    You are right.
    But where would you place 11404 or 11406? Taking the maximum diameter he noted or would you ask him to be more specific about the size , the specimen being sent for Path and reported ,I am sure there would be a measurement. I feel that you can get it from the Path (macroscopic ) report too.

  3. #3

  4. Default
    Trent, Sorry I had a flash of thought .You are right as for as we take it as integumentary, benign tumor in some of the regional integumentary system.
    But the clavicle belongs to the shoulder region and the inferior border of clavicle enjoys the merit of being a part of it.
    in that case your thought process of going for 20000 series is right .
    the code 23075 would be more appropriate, when we have a specific code. Dont you think so.Your doubt has real meaning to it. I got the shot from your doubt.
    Thank you

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