I was wondering if I could get some advice. For the soft tissue tumor codes, should they only be reported for soft tissue tumors only? Here is an example:
The patient comes in for surgery for a soft tissue mass of right ankle. The provider goes through the skin and subcutaneous tissue to excise the 3 cm lesion. The lesion appears to be just above the retinaculum. The skin and subcutaneous layers were closed. The lesion was sent to pathology, where pathological analysis revealed the mass to be an organizing thrombus.
If it was a soft tissue tumor, I would've used:
Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater
Now we have an organizing thrombus. Could we still use the 27632 with diagnosis 453.6, or should I use the following CPT with the corresponding diagnosis:
Biopsy, soft tissue of leg or ankle area; superficial
Thank you all for your help.
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