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Help with correct procedure code

  1. Default Help with correct procedure code
    Medical Coding Books
    We had a physician perform a procedure on a patient in a family practice office. The physician's procedure note reads:

    " Cheesy sebaceous material removed through pore already formed, no incision was necessary. Cyst wall incompletely removed with hemostats. Discussed possibility of recurrance."

    I am having trouble deciding which CPT code would be most appropriate for the service performed. Any thoughts are much appreciated!

  2. Default
    Could you use "removal of foreign body" and then just go to the appropriate site from which it was removed..?

  3. Default Help with correct code
    As no foreign body was removed, it would be inappropriate to code as if it were. Look at 10060-52 as no incision was performed.

  4. #4
    Milwaukee WI
    Default No incision = E/M code
    I'm sorry you cannot use 10060 if you did not make any incision.

    Without seeing the full documentation, it's hard to tell, but it is possible that the only thing you'll be able to code is the E/M.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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