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Not sure what CPT to use for this removal?

  1. Default Not sure what CPT to use for this removal?
    Medical Coding Books
    When I work this up by excision I get 11402. But the description does not match what the provider did. Description says physician makes a full thickness incision throught the dermis with a scalpel. He didn't use a scalpel...?????
    Path report came back SK

    CC: Growth Under R arm -possibly a mole .

    History of Present Illness:
    no energy, apathetic. depression.
    night sweats. symptoms for last couple years. on paxil and has been higher does which helped more.

    enlarging growth under right arm

    Vital Signs:

    Patient Profile: Years Old
    Height: 71 inches (177.8 cm)
    Weight: 000 pounds
    BMI: 32.05
    BSA: 2.24
    Temp: 96.1 degrees F tympanic
    Pulse rate: 66 / minute
    Pulse rhythm: regular
    BP sitting: 120 / 80 (left arm)
    Cuff size: regular

    Vitals Entered By:
    Physical Exam

    well developed, well nourished, in no acute distress.
    no masses, thyromegaly, or abnormal cervical nodes. no bruit. no bruit.
    clear bilaterally to auscultation.
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    2 cm nodular skin lesion in right axilla. somewhat of pedunculated base

    Impression & Recommendations:

    Problem # 1: SKIN LESION (ICD-709.9)
    2 cm nodular skin lesion. 1% lido with epi for local. surgitron excision. sent for path. base cauterized.
    wound care instructions given
    Excision of Lesion (EXCLES)

    Problem # 2: FATIGUE (ICD-780.79)/NIGHT SWEATS
    check labs. may be depression related but r/o metabolic issue
    Basic Metabolic Panel (BMP)
    TSH (TSH)
    Testosterone, Total (TESTOT)
    Hemogram (CBC no diff) (HGMP)
    Other (Oth)

    Medications Added to Medication List This Visit:
    1) Ranitidine Hcl 150 Mg Tabs (Ranitidine hcl) .... One tab po qd

  2. Default which code
    I would go with the 11402, because the Surgitron is an electronic cautery scalpel.

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