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Forehead lipoma

  1. #1
    Default Forehead lipoma
    Medical Coding Books
    Stuck on this one any souggestions ? Would this be a 11446 with a closure code or would it be best to use cpt code 21012 ?
    want to go with 21012 but not sure ,since it is
    a lipoma

    PREOPERATIVE DIAGNOSIS: Left forehead mass.
    POSTOPERATIVE DIAGNOSIS: Left forehead mass, clinically lipoma.
    OPERATION: Excision of left forehead mass around 4 cm.

    After appropriate informed consent was signed, the patient was taken to the operating room, transferred to the operating table and underwent general anesthesia via laryngeal mask. The area was prepped and draped in the normal fashion. A time-out had been performed to verify the correct patient and correct procedure. Incision was made in the left forehead mass and lifted up along the Langer's lines for around 4 to 5 cm. Dissection was carried down through the skin and subcutaneous tissues until we got to the mass. The mass that appeared to be clinically lipoma went to the skull, but it was not clearly in the skin. It was removed with great care, making sure we did not damage any nerve or tissue. This was done with great care. The mass was then removed. The entire mass was then sent to Pathology for permanent section. Excellent hemostasis was noted to be obtained with pressure. The wound was closed in two layers with 3-0 Vicryl and then 4-0 Vicryl for the skin. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure and transferred to the recovery room in stable condition.

  2. #2
    I think code 21012 is appropriate in this case.

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