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please HELP with lesion excision and repairs

  1. #1
    Default please HELP with lesion excision and repairs
    Medical Coding Books
    Need help with CPTs. Thanks.

    procedure: excision of right forearm and soft tissue masses.
    Lesion sizes--Lesion #1 (2 cm. ) Lesion #2 (3 cm.)
    note: the provider says it was a layered repair. Lesions were benign.

    op note: A vertical incision within the direction of the limb was made over the more superior lesion after infiltrating the skin and soft tissue surrounding both lesions. Some dense adipose appearing tissue was found beneath the incision. An approximately 3 cm area of dense fatty tissue was removed with a combination of blunt and cautery dissection. A small vein was encountered which was clamped and suture ligated. The removed tissue was passed off the field for permanent pathology. The wound was packed and attention was turned to the more distal lesion. This was removed in a similar fashion and again dense appearing adipose tissue was seen. Approximately 2cm x 2 cm of tissue was removed. Small venules were cauterized as needed. Both wounds were irrigated and bleeding points within the subcutaneious tissue were controlled with cautery as needed. The wounds were closed with deep dermal sutures of 4-0 Vicryl followed by running subcuticular sutures of 4-0 Monocryl. The wounds were cleaned, dried and dressed.

  2. #2
    Columbia, MO
    I see documentation of two excisions which you said path says benign so two codes for the benign excision with a 59 modifier on one. However I do not see a layered repair documented. He describes dermal sutures with subcuticular sutures but that is a simple repair, a layered repair would involve subcutaneous tissue as well. I do not have access for the actual codes as my books are packed but they should be easy to locate in your book.

    Debra A. Mitchell, MSPH, CPC-H

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