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Excision - Family Practice provider

  1. #1
    Default Excision - Family Practice provider
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    I have a Family Practice provider that did a;
    Procedure: Excision
    Location: Trunk
    Description: Lipomatous Mass
    Lesion Size: 3.0 cm.
    Method: Excision of lesion through the full thickness of the dermis into the fat was performed. Lipomatous mas separated from the fascia.
    Anesthesia: Lidocaine 2% with epinephrine
    Closure: Intermediate
    Path:Epidermal cyst, ruptured with granulomatous inflammation
    Intermediate repair
    Indication: Due to the large hole left by excision of the lesion simple closure could not be performed. The deeper layers of the defect had to be approximated to reduce tension on the suture line and and to result on optimal healing of the surgical site. The subcutaneous tissue was approximated using 8# of 3.0 Vicryl sutures. The epidermis was carefully closed using 10# of 3.0 Nylon sutures.
    Length defect: 5.0 cm long

    Provider billed: 11403
    I disagree with this but he states he is correct. Please provide an opinion and Thanks as always for everyones great help.

  2. #2
    Columbia, MO
    It looks to me as though the excision (11403) was the approach for the removal of the lipoma (21930), and not 2 separate procedures. Once a definitive procedure is performed (21930) you cannot charge for the approach (11403), and there was only one closure as there is only one defect created, and the 21930 includes the closure.
    Now there is a debate amongst experts in the field as to whether this type of scenario should use the 11403 OR the 21930 here is an excerpt from the Family Practice magazine:
    According to CPT, there are actually a number of differences between 11403 and 21930. Code 11403 is for “excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm,” and it appears in the “surgery/integumentary system” section of the CPT manual. It is for full-thickness (through the dermis) removal of benign lesions of the skin or subcutaneous tissues (e.g., cicatricial, fibrous, inflammatory, congenital and cystic lesions), including local anesthesia and simple (nonlayered) closure. Code 21930 is for “excision, tumor, soft tissue of back or flank,” and it appears in the “surgery/musculoskeletal system” of the manual. In the Medicare Fee Schedule database, 11403 has a 10-day global period and 21930 has a 90-day global period, suggesting that 21930 is a more extensive procedure.

    There is nothing in the descriptor of 21930 that would obviously preclude its use in your situation. A lipoma is a fatty tumor, and the physician did excise it from the soft tissue of the back. The only indicator that this code may not be appropriate is the 90-day global period that Medicare attaches to this procedure. Services with a 90-day global period typically represent more involved procedures that are not usually done in a physician’s office. You may want to review your service in light of the information provided above to decide which code most accurately identifies it.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Milwaukee WI
    Default 21930
    Based on the given documentation ... I would have coded only the 21930.

    I agree with Debra that you may get a denial from the insurance company for POS. However, there are other "major" procedures with a 90-day global that are routinely done in an office ... e.g. closed treatment of a fracture without manipulation.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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