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Cpt 21930?

  1. Default Cpt 21930?
    Medical Coding Books
    Need help with the following: Doc wants to use CPT 21930 but I'm not too sure this is correct. Thanks!!! I'm thinking 21932 but not sure what throws me off is the drainage of pus. path report states: inflamed epidermoid cyst

    DX: Infected sebaceous cyst in the right back
    1.Culture from the cyst.
    2. Sebaceous cyst in its entirety

    FINDINGS:Infected cyst.
    INDICATIONS:The patient is a 38‑year‑old gentleman who presented to my office with a right back cyst that was tender and increasing in size. I explained the risks and benefits of the procedure and he gave me his full consent.

    OPERATIVE PROCEDURE:He was brought to the operating room where timeout was performed to myself. Anesthesia and nursing teams confirmed the appropriate patient and procedure. Clindamycin was given 30 minutes prior to induction. Conscious sedation was given. The patient also received local sedation. The patient was placed prone. The right back was prepped and draped in normal sterile fashion. I anesthetized the area with 30 mL of local anesthetic.
    I made a transverse incision approximately 3 cm over the area. Immediately, I removed approximately 10 or 15 mL of pus and this was cultured. I then resected the entire cyst cavity. It was quite deep and extended toward the muscle fascia, but I do not believe it adhered to the the muscle fascia. I enucleated the entire area with copious amounts of irrigation. I achieved hemostasis. I then closed the deep dermal layers with 2‑0 Vicryl. I then closed the skin with 2‑0 Vicryl mattress sutures. Bacitracin was applied to the skin.

  2. #2
    I would use either 21930 or 21931, but you need the size of tumor. Dication states did not adhear to muscle. 21932 is subfascial.


  3. Default
    thank you.

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