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Need help on Coding Lesion removal

  1. #1
    Default Need help on Coding Lesion removal
    Medical Coding Books
    SUBJECTIVE:

    CC:
    Mr. X is a 76-year-old male. He is here for skin tag removal.

    Current Problems:
    Atypical mole
    Congestive heart failure
    Hip pain
    Osteoarthritis
    Other primary cardiomyopathy

    Immunizations:
    None

    Allergies:
    Morphine:
    Codeine:
    Lortab:
    Cipro:

    Current Medications:
    Coreg 25mg Tablet Take 1 tablet(s) by mouth bid
    Lasix 40mg Tablet Take 1 tablet(s) by mouth bid
    Prinivil 20mg Tablet Take 1 tablet(s) by mouth twice daily
    Ultram 50mg Tablet take 1-2 po q6-8hrs
    Darvocet-N 100 100mg/650mg Tablet one po as needed for pain q 8 hours
    Allopurinol 100mg Tablet Take 1 tablet(s) by mouth daily
    Flagyl 500mg Tablet Take 1 tablet(s) by mouth tid for 10 days
    Prilosec 20mg Capsules, Extended Release Take 1 capsule(s) by mouth daily

    OBJECTIVE:

    Vitals:

    Current: 7/22/2008 4:52:44 PM
    Ht: 73.2 inches; Wt: 270 lbs; BMI: 35.43
    T: 97.6 F (oral); BP: 95/55 mm Hg (left arm, sitting); P: 69 bpm (left arm (BP Cuff), sitting); R: 16 bpm

    Procedures:
    Atypical mole

    Procedure Note:
    Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed.
    Benign appearing lesion #1 is located on right lower lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with cautery. The specimen is sent for pathology review.
    Benign appearing lesion #2 is a seborrheic keratosis located on right upper lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The wound is closed with 3 simple interrupted stitch(es) using 4-0 Ethilon. The specimen is sent for pathology review.
    Lesion #3 is round brown with white outer border, roots - came out in ball - center of back. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
    Benign Lesion #4 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
    Benign Lesion #5 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is not sent for pathology review, as it is clearly benign.

    Congenital accessory skin tags

    Procedure Note:
    Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed. Multiple skin tags are located left side of scalp (in hair) above left ear. A total of one skin tag(s) removed today. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The method of removal is shave excision. Hemostasis is achieved with cautery.


    ASSESSMENT:

    238.2 Atypical mole
    757.39 Congenital accessory skin tags

    PLAN:

    Atypical mole

    Orders:
    Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
    A4550 Surgical trays (x1)
    Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 1.1 to 2.0 cm
    A4550 Surgical trays (x1)
    Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 1.1 to 2.0 c
    Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 0.6 to 1.0 c

    Congenital accessory skin tags

    Orders:
    Removal of skin tags, multiple fibrocutaneous tags, any area; (initial 1-15)


    CHARGE CAPTURE:

    Primary Diagnosis:
    238.2 Atypical mole

    Orders:
    99211 Office/outpatient visit; established patient, level 1

    757.39 Congenital accessory skin tags




    I think it would code:
    17110
    11401
    11402
    11301
    11302

    no office visit....


    Please help, I'm confused

    Thanks
    Kristie Stokes CPC-A
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. #2
    Default
    I didn't see any mention of lesion size in the description of how the procedure was done, just at the bottom. I'm not sure where you got sizes, so I can't say an exact CPT#. You do seem to be missing one of the excisions, and the 17110 is for destruction of benign lesions, except for skin tags. I would use 11200 instead.

    11400-11406 (depending on sizes) for the 3 excised back lesions
    11300-11303 (depending on sizes) of the 2 shaved back lesion
    11200 for the skin tag

    I also wouldn't charge an OV.

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