CPT Knowledgebase - Sep 26, 2022

What is the appropriate code to report the removal of a soft-tissue mass located at the ankle? The physician made a 3.5-cm longitudinal incision over the medial aspect of the left ankle and dissected bluntly around the soft-tissue mass, which appeared to be filled with a white fluid consistent with gout tophi. A 1.5-cm mass that was connected to the periosteum was excised, involving a 1.0-cm diameter area of the medial malleolus with a depth of approximately 5 mm. Once the tophus was excised, a curette was used to debride the defect in the bone to stimulate bleeding in order to heal by itself.

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