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Thread: How would you code this procedure?

  1. #1

    Default How would you code this procedure?

    AAPC: Back to School
    I'm confused when you use the integementary codes and when you use the musculoskeletal codes for lesion excision? Please help
    PREOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.

    POSTOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.

    NAME OF PROCEDURE: Right neck mass excision of lipoma with a small fasciotomy, closure of wound of approximately 2 cm.

    ANESTHESIA: General.


    SPECIMENS: Fatty tissue to pathology.

    ESTIMATED BLOOD LOSS: Less than 5 mL.

    FINDINGS: the patient is a pleasant 36 -year-old white female with a history of the above noted diagnosis. Operative findings included a right posterior neck mass that was consistent with lipoma beneath the fascia overtop of the trapezius muscle.

    TECHNIQUE: the patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. Appropriate drapes were placed Attention was turned to the right neck. The neck was prepped and draped in usual sterile fashion. The area was infiltrated with 2% lidocaine with 1-100,000 epinephrine. Incision was made about 2 cm in length with a sharp knife. Dissection was carried through the subcutaneous fat down to the superficial cervical fascia. This was sharply incised and the lipoma was identified and carefully dissected from the fascia and underlying trapezius muscle. Part of the muscle was excised. The fascia was left open in a fasciotomy type procedure for depression. The base and some little residual fat tissue was cauterized with bipolar cautery. The deep tissue was then closed with 5-0 Vicryl sutures and skin closed with running 5-0 nylon suture.

    Sterile dressing was applied. The drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken and transported in stable condition to the recovery room having tolerated the procedure well.

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    I think that the fact that the lipoma was beneath the fascia, and that some muscle was excised means that it would be from the musculoskeletal system, but I could be wrong. I want to think that the integumentary system only goes as far as subcutaneous structures (eg, fat), but I don't have my book with me - I'm pretty certain it's covered in the surgery guidelines - maybe the ones specific to the integumentary system. Look around the pages with definitions of 'simple', 'complex' etc. Sorry, I know that probably wasn't much help!

  3. #3

    Default should be coded from body parts


    Lipoma was beneath the fascia, and that some muscle was excised, so it should be coded from body part but make sure we need margins for that aslo as per description lipoma size is approximately 1 cm and in body of the report it is about 2 cm so first we need to hold for path and after that we have to report cpt 21556 if diameter is less than 5 cm and 21554 if diameter is more than 5 cm. I think this will help you.

    Thanks and Regards

    Sanjeev Sonkar, CPC

  4. #4
    Join Date
    Apr 2007
    Albany, New York


    Based on the Procedure note, depth is definitely deeper than "Integumentary" system.
    Once you are below fascia, you are heading into the "Soft Tissue", or Musculoskeletal level of a body site.

    I do disagree with a comment in the last response.......lesion size used to determine the CPT code for excision of a lesion is not determined by the pathology report.
    That information should be provided by the surgeon in the OP report.
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
    Join Date
    Apr 2007
    Salisbury, MD


    A lipoma is a benign tumor composed of adipose tissue.

    Answer: 21556: Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm.

    MD documents that he dissected from the fascia and underlying trapezius muscle.

    Just a side note, don't let the word integument keep you away from coding things that are deeper than what you normally think of as "integument," just for a totally unrelated example, the debridement codes go down to the bone…..

    11012 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone.

    However, in this case, 21556 seems most appropriate.

    Just look at code descriptors carefully with diagnosis.

    Have a great day!

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