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Lesion or cyst?

  1. #1
    Default Lesion or cyst?
    Medical Coding Books
    We have a patient where the doctor, per the operative report, removed a penile cyst and it was sent to pathology. The doctor's manager who enters charges, wants to bill CPT 11422 which is the excision of a benign lesion 1.1 to 2.0 cm. The pathology report does show the tissue measured 2.1 x 0.3 x 0.2. Is this correct code for cyst excision?

    Urology office

  2. #2
    The sizes of the lesion/cyst should be taken from the operative report, not the pathology report. I think more information (op note) is needed to assist you with this case (specifically-the procedure in which he used to remove this lesion/cyst). What was the diagnosis on the pathology report?

  3. #3
    The op report indicates there was an excision of the cyst tracking from mid penile area down to the penile scrotal region. (This is the diagnosis section!) It doesn't really state what he used to make the incision. Any input would be appreciated.


  4. #4
    please review 54060 for possible use in this case

  5. #5
    Thank you so much for your help.


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