tci Outpatient Facility Coding Alert - 2017 Issue 3

Reader Question: Missed Excision Measurement

Question: We have an op report for excision of a “subcutaneous mass” of the back with intermediate repair, but it doesn’t state the size of the excision. The pathology report returned as “lipoma, 2.6 cm diameter.” How should we code this? Ohio Subscriber Answer: The best procedure code you can select is 21930 (Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm) based on the information you have. Opportunity: Because tissue shrinks during processing, waiting to use the excision measurement from the pathology report instead of the time of surgery...

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