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Need help

  1. #1
    Location
    NEW ORLEANS
    Posts
    956
    Default Need help
    Medical Coding Books
    how would you code this .soft tissues was noted ,so would axillary be by arm, shoulder , breast < usually axillary says armpit -so does armpitmean forearm -25075? Someone else told me to try 21552 ,
    just a note opath report came back as benign breast parenchyma ?

    POSTOPERATIVE DIAGNOSIS: Left axillary mass.

    PROCEDURE PERFORMED: Excisional biopsy of left axillary mass.

    ANESTHESIA: General.

    ESTIMATED BLOOD LOSS: Minimal.

    CLINICAL HISTORY: A 16-year-old female with a left axillary mass, which has not resolved with oral antibiotics.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in supine position. The left axilla was prepped and draped in sterile fashion. An elliptical incision was made in the direction of the Langer's lines in the left axilla. Electrocautery was used to dissect through the subcutaneus tissue to excise this soft tissue mass with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. It was inspected and found to be hemostatic. Dissection was not deep enough to be in the area of any of the deep vessels or nerves of the axilla. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and the skin was closed with interrupted 4-0 nylon suture. A sterile dressing was applied. 10 cc of 0.25% Marcaine was injected for local anesthesia. Sterile dressing was applied. The patient tolerated the procedure well.
    Last edited by codedog; 12-29-2011 at 04:11 PM.

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by trent123 View Post
    how would you code this .sost tissues was noted ,so would axillary be by arm, shoulder , breast < usually axillary says armpit -so does armpitmean forearm -25075? Someone else told me to try 21552 ,
    just a note opath report came back as benign breast parenchyma ?

    POSTOPERATIVE DIAGNOSIS: Left axillary mass.

    PROCEDURE PERFORMED: Excisional biopsy of left axillary mass.

    ANESTHESIA: General.

    ESTIMATED BLOOD LOSS: Minimal.

    CLINICAL HISTORY: A 16-year-old female with a left axillary mass, which has not resolved with oral antibiotics.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in supine position. The left axilla was prepped and draped in sterile fashion. An elliptical incision was made in the direction of the Langer's lines in the left axilla. Electrocautery was used to dissect through the subcutaneus tissue to excise this soft tissue mass with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. It was inspected and found to be hemostatic. Dissection was not deep enough to be in the area of any of the deep vessels or nerves of the axilla. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and the skin was closed with interrupted 4-0 nylon suture. A sterile dressing was applied. 10 cc of 0.25% Marcaine was injected for local anesthesia. Sterile dressing was applied. The patient tolerated the procedure well.
    The description of the procedure looks like 11100 Biopsy of skin, subcutaneous tissue and or mucous membrane (including simple closure), unless otherwise listed; single lesion. The other codes suggested do not work for the location of this procedure or what was actually done. Just a simple excision from the upper chest wall/armpit area of a subcutaneous cyst which was sent for pathology.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default
    Being breast tissue I would suggest 19120. Any other thoughts? Hope this helps!!
    Last edited by bethh05; 01-11-2013 at 11:55 AM.

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