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excision of sebaceous cyst-I am reviewing

  1. #1
    Default excision of sebaceous cyst-I am reviewing
    Medical Coding Books
    I am reviewing a note for an excision of a sebaceous cyst. I am wondering if I should also be using a repair code as well.

    This is the note:

    2 cm sebaceous cyst on mid back, 2 ml of lidocaine 1% w/ epi. The lesion was located on the mid back, the patient was preppred and draped in teh usual sterile fashion using betadine and alcohol. Excision of cyst and contents. The cutaneous layer was closed with 3, interrupted 4-0 nylon sutures.

    After reviewing this note I am wanting to use cpt 10040 and possibly the repair code 12011. I need to look up CCI edits before doing this but wanted to know if I am on the right track here. Any takers.
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  2. Smile Hi
    Hi Roxanne Thames;

    Actually your documentation was not clear much. I am trying to explain you. sebaceous cyst was excised from back. Scenario for this type of report is, first look type of incision, if ellipitically removed then we need diameter to code this, so we need path. If path comes you have to look if skin was involved if yes then take maximum diameter from path or from op note. Then choose coded according to body part.

    To report closure, read note carefuly if layered closure was performed then we can take intermidiate code if simple repair is performed than no need to coded seperately, which is inclusive in excision code.

    you have taken 10040, which is acne code. As per note, your code should be 11400 series as per diameter and simple repair is there so no need to code simple repair.

    hope this will help

    Thanks and Regards

    Sanjeev Sonkar, CPC

  3. #3
    I initially was going with a 114__ code but when I asked the doctor for the margins for this cyst removal. He says there were no margins as he just cut out the cyst and the contents, which I equated to removal of the entire cyst. Which is why I thought maybe I should be using the 10040 code instead of 114__.

    Thank you for your input Sanjeev
    Last edited by rthames052006; 07-27-2011 at 09:03 AM.
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4
    Milwaukee WI
    Roxanne ... here's the lay description (from Encoder Pro) for 10040
    The physician makes a small incision through the skin overlying a lesion, or multiple lesions, such as comedones (blackheads), cysts, or pustules for acne surgery. The skin over the lesion is removed. The lesion is opened with a surgical instrument and the fluid is drained for secondary healing. The lesion may be removed or marsupialized by exteriorizing the cyst and making a pouch where it used to be enclosed. No sutures are needed. Do not bill a benign lesion excision code (11400-11446) and chemical exfoliation for acne (17360) on same date of service with 10040.

    I think you really have a 11402. Why? From the procedure note it was in the cutaneous layer, so you can't code from the musculoskeletal section. The diameter of the cyst is sufficient measurement to code this (physician has stated there were no margins, so the size of the cyst is the excised measurement). Only simple closure is reported, so this is included in the excision code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default Thanks much!
    Thank you Tessa. I think what really threw me was the fact that he said there was no margin, I "assumed" all excision had to have a margin" so I was thinking (again) that I would need to code to the measurement as 2cm only without having any documentation of margins.

    I appreciate all who responded. I'm thinking since this is my new specialty I should sit in on a few excisions/shavings/ destruction procedures so I get a visual of what is being done.

    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

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