Well he can "say" that it was more complex, but he did not document that.
To use 21011 thru 21014 he will need to stipulate how deeply he dissected ("to the mass" doesn't tell me how deep the mass was - subcutaneous? subfascial? Intramuscular?) -and- the size of the mass (Cm measured at widest diameter). And don't forget that closure is INCLUDED with codes in the musculoskletal section of CPT.
You should also have confirmation from pathology that this was a lipoma.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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