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42810 vs 21013

  1. #1
    Default 42810 vs 21013
    Medical Coding Books
    AFTER reading operative report I tend to want to code this as 42810 ,but doc office coder say they are billing 21013, difference of opinion, if I am wrong , please let me know

    PREOPERATIVE DIAGNOSIS: 2-cm right postauricular mass.

    POSTOPERATIVE DIAGNOSIS: 2-cm right postauricular mass – first arch branchial cleft cyst.

    PROCEDURE PERFORMED: Excision of right postauricular mass.

    OPERATIVE PROCEDURE: was given adequate preop sedation and brought to the operating room, where was placed in a supine position and placed under general endotracheal anesthesia. The head was turned to the left exposing the right side of the head. There was a 2 cm x 2 cm mass posterior to the right auricle between the hairline and the auricle. It was movable. It was spongy in texture. A vertical incision was made along the hairline and dissection over the mass was done; it was a cyst, which was dissected free of the subcutaneous tissue and had a small tract, which went in the direction of the external auditory canal and then ended. The mass extended all the way to the periosteum. It was completely removed. Small bleeders were electrocoagulated with suction Bovie cautery with an estimated blood loss of 1 to 2 cc and the wound was closed in layers with 4-0 Vicryl and a 6-0 monochromic was used to close the skin. No drains were utilized. .

  2. #2
    path report came out as first brancial cleft cyst

  3. #3
    My money is on your code, 42810, Trent. Maybe the provider coder got hung up on "mass" or didn't read the report?

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