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soft tissue removal or not?

  1. Default soft tissue removal or not?
    Medical Coding Books
    doc wants to bill a soft tissue removal 28xxx musculoskeletal code for the following but the report to me doesn't support this code.... it doesn't state the depth of the lesion


    Diagnosis: Unspecified soft tissue neoplasm of the left foot.

    Operation: Excision of benign neoplasm of left foot.

    GROSS FINDINGS:
    Examination of the left foot reveals that there is an exquisitely painful lesion at the plantar aspect of the second metatarsal head. patient has had multiple of these same lesions in different areas of her feet over the past few years. All have responded well to surgical excision. She understands the need for this procedure and possible risks, benefits, complications, and alternatives and has consented to the procedure listed above.

    OPERATIVE PROCEDURE:
    After obtaining an informed written consent, patient was taken to the OR and placed on the operating table in the supine anatomical position and positioned for the administration of local anesthesia. She received a total of 6 cc of 0.5% Marcaine with epinephrine. The block was used in conjunction with intravenous sedation. The left limb was prepped and draped in the usual sterile fashion for surgery. Attention was then directed to the lesion at the plantar aspect of the left foot. With the use of #15 blade, two converging semi elliptical incisions were created encompassing the lesion. The wedge of the skin including the lesion was excised. The undersurface of the lesion appeared to be a massive tissue visually consistent with nerve tissue. The lesion was excised as a single unit and sent for pathological examination. The site was flushed with copious amounts of normal sterile saline. Deep closure was achieved with 3 0 Vicryl and the skin margins were re approximated with 3 0 nylon. The site was dressed with sterile Adaptic, sterile 4x4, sterile Kling, and an Ace bandage.

  2. #2
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    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by BFAITHFUL View Post
    doc wants to bill a soft tissue removal 28xxx musculoskeletal code for the following but the report to me doesn't support this code.... it doesn't state the depth of the lesion


    Diagnosis: Unspecified soft tissue neoplasm of the left foot.

    Operation: Excision of benign neoplasm of left foot.

    GROSS FINDINGS:
    Examination of the left foot reveals that there is an exquisitely painful lesion at the plantar aspect of the second metatarsal head. patient has had multiple of these same lesions in different areas of her feet over the past few years. All have responded well to surgical excision. She understands the need for this procedure and possible risks, benefits, complications, and alternatives and has consented to the procedure listed above.

    OPERATIVE PROCEDURE:
    After obtaining an informed written consent, patient was taken to the OR and placed on the operating table in the supine anatomical position and positioned for the administration of local anesthesia. She received a total of 6 cc of 0.5% Marcaine with epinephrine. The block was used in conjunction with intravenous sedation. The left limb was prepped and draped in the usual sterile fashion for surgery. Attention was then directed to the lesion at the plantar aspect of the left foot. With the use of #15 blade, two converging semi elliptical incisions were created encompassing the lesion. The wedge of the skin including the lesion was excised. The undersurface of the lesion appeared to be a massive tissue visually consistent with nerve tissue. The lesion was excised as a single unit and sent for pathological examination. The site was flushed with copious amounts of normal sterile saline. Deep closure was achieved with 3 0 Vicryl and the skin margins were re approximated with 3 0 nylon. The site was dressed with sterile Adaptic, sterile 4x4, sterile Kling, and an Ace bandage.
    It would appear you just need to query the doctor about the size of the tumor, either larger or smaller than 1.5cm and whether it was subcutaneous or subfascial. This information can be added as an addendum to the current op report to validate the code.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    yes..... that would be great IF only I can communicate with the doctors... I'm billing for an ASC... so based on what I do have.... I should then go with the integumentary section?

    Thanks

  4. #4
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by BFAITHFUL View Post
    yes..... that would be great IF only I can communicate with the doctors... I'm billing for an ASC... so based on what I do have.... I should then go with the integumentary section?

    Thanks
    Yes, and you will have to default to the code for the lesser repair.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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