What are the incorrect or missing codes for this scenario? LOCATION: Outpatient,

Question

What are the incorrect or missing codes for this scenario?

LOCATION: Outpatient, Hospital

PATIENT: Casey Wild

PRIMARY CARE PHYSICIAN: Leslie Alanda, MD

SURGEON: Mohamad Almaz, MD

PREOPERATIVE DIAGNOSIS: Lipoma, right lumbar area

POSTOPERATIVEDIAGNOSIS: Lipoma,rightlumbararea

PROCEDURE PERFORMED: Excision of lipoma, right lumbar area

ANESTHESIA: General endotracheal with 2 cc of 1% Xylocaine with 1:100,000 epinephrine.

SURGICAL FINDINGS: 3.5-cm diameter subcutaneous lesion sitting on the right latissimus dorsi muscle morphologically resembling a lipoma.

DESCRIPTION OF PROCEDURE: The patient was intubated and turned to a prone position. The lesion was prepped with Betadine scrub and solution and draped in a routine sterile fashion. I injected about 2 cc of 1% Xylocaine with 1:100,000 epinephrine over the site of the lesion and around it. I excised an ellipse of skin that I left attached to the lipoma and carried dissection down to the superficial muscular fascia, from which I separated the lipoma. I cauterized the bleeding and closed the wound with subcutaneous 2-0 Monocryl to close the dead space and subcuticular 3-0 Monocryl. I used Steri-Strips to appose the skin edges and used Kerlix fluffs and Elastoplast for the remainder of the dressing. The patient tolerated the procedure well and left the operating room in good condition.

PATHOLOGY REPORT LATER INDICATED: Lipoma

One or more of the following codes are reported incorrectly for this case. Indicate the incorrect code or codes.

SERVICE CODE(S): Lesion excision, 11404

ICD-10-CM DX CODE(S): Lipoma, D17.39

INCORRECT/MISSING CODE(S):

Explanation / Answer

21930

The lipoma is in a deep subcutaneous area, in submuscular location (the physicians report of .5-cm diameter subcutaneous lesion sitting on the right latissimus dorsi muscle morphologically resembling a lipoma.), the appropriate code from the musculoskeletal system (eg, 21930, Excision, tumor, soft tissue of back or flank) can be used.

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