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Do I code this to the smallest size

  1. #1
    Location
    NEW ORLEANS
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    954
    Default Do I code this to the smallest size
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    There is no size ,so do I code this to the smallest size or do I look at path report ?Also,path report came out as a lipoma, but I only see the skin was closed with sutures , so is this integumentary?
    Thanks

    PREOPERATIVE DIAGNOSIS: Right arm mass.

    POSTOPERATIVE DIAGNOSIS: Right arm mass.

    PROCEDURE PERFORMED: Excisional biopsy of right arm mass.

    ANESTHESIA: MAC.

    ESTIMATED BLOOD LOSS: Minimal.

    CLINICAL HISTORY: This is a patient with a right arm mass, consented for biopsy.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a supine position. The right arm was prepped and draped in a sterile fashion. A 10 cc of 1% lidocaine with epinephrine was injected for local anesthesia. A linear incision was made directly over the mass and subcutaneous tissue. A mass was excised with combination of blunt dissection and electrocautery with negative margins. It was consistent lipoma. The wound was inspected and found to be hemostatic and was irrigated with normal saline. The skin was closed with sutures. The patient tolerated the procedure well.

  2. #2
    Location
    Kansas City, MO
    Posts
    431
    Default
    Do not use the skin codes. The lipoma/mass excision should be coded using the musc/skel section codes. If you have access to the path, you'll want to check that the size of the mass, otherwise, yes, use the smallest size...but let your doc know they need to document the size
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Location
    NEW ORLEANS
    Posts
    954
    Default
    thanks linda path report stated as received a 3 x3x1.2 cm 3 gram tan yellowtissue . So I guess this is 3 cm
    Last edited by codedog; 11-10-2011 at 03:27 PM.

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