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Repost procedure note help!

  1. Default Repost procedure note help!
    Medical Coding Books
    I need help with this note for removal of lesion. Dr. gave 11100 and 11101, no modifier. I think it should be 11400 - 53 and 11406. So who is right?

    Assessment and Plan
    Ambulatory Assessment/Plan:
    759.6 Epidermal nevus

    214.9 Lipoma

    Additional Plan Details:
    759.6 Epidermal nevus-cyst left midback

    214.9 Lipoma

    sterile prep to both lesions
    anest c xylo c epi
    back cyst removed in toto after ellipse cut
    defect clsed c 2 3-O sutures

    left flank lesion incised c scalpel
    removed top fatty and CT
    lesion went deep
    closed c 2 3-O sutures
    if desires removal will send to surgery

    remove sutures 7 days
    wound care explained
    call c problems

    Nursing Chief Complaint: mole removal

    Physician: here for lesion removal x 2
    Height 70 in / 177.80 cm
    Weight 172 lbs / 78.017893 kg
    BSA 1.97 m2
    BMI 24.7 kg/m2
    Temperature 98 F / 36.66 C - Oral
    Pulse 68
    Blood Pressure 100/80 Sitting, Left Arm
    Personal Medical History
    Personal medical history: Hx of: High cholesterol, Depression,
    No hx of: Coronary Artery Disease

    Social History
    Social history:
    Marital Status: Married
    Occupation: owner-pizza parlor

    left lower abd/flank c fatty feeling cystic lesion
    round, nontender, no skin chnages

    left midback-8 mm oval lesion, cystic feel

    General Appearance: NAD

  2. #2
    Milwaukee WI
    Default Repeat post
    I answered in the other post.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Columbia, MO
    The note lacks substance for coding a procedure in my opinion. You know from the end that there is an 8mm oval lesion but you really do not know if this was the one removed. From the note you have no idea if this was excised or shaved and how large the incision was there is no mention of margins. There is no reference in the note to the pathology of the lesion removed. As to the second procedure I cannot tell if something was removed and submitted for path or if it was just looked at and closed. The note as it stands looks like an E&M, I see that something was done but not to an extent that it can be coded.

    Debra A. Mitchell, MSPH, CPC-H

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