My doc performed a right groin exploration and excision of scar tissue. The patient had a prior RIH in 2008. Not sure which CPT code to use. This was performed an an ambulatory surgical center. Do I stay in the integumentary at 10120/10121?
Thank you in advance for your help.
Peggy
This is not enough information - did they open the groin up or just stay on the surface? Have to know this. Could you provide the complete op note?
Suzanne Leder, BA, M.Phil., CPC, COBGC
Executive Editor of the Ob-gyn Coding Alert,
Orthopedic Coding Alert, and Otolaryngology Coding Alert
Here is the OP note
Local anesthestic was used to infiltrate the skin along its previous scar. Using a scalpel, a semi-elliptical incision was made around his previous scar. Electrocautery was used to dissect through the subq tissue. The patient had a palpable nodule along the medial aspect of his incision. This was dissected using electrocautery. The remainder of the scar tissue was also excised using electrocautery and this was passed off as a specimen. Additional local anesthetic was then injected into the area. 3-0 vicryl was used to reapproximate the dermis. 4-0 monocryl was used to reapproximate the skin in a subq fashion. Dermabond was applied.
Path report: benign fibroadipose tissue and skin with dermal fibrosis consistent with scar.
Thanks again for your help.
Peggy
Here is what my Consulting Editor, Melanie Witt, says:
"In that case it was an intermediate repair, not complex, but they removed a lesion (size will matter) so could bill 12031-12037 for the repair and also 11400-11406. Again the size of the removed and sutured area must be documented.
Melanie"
Hope this helps!
Suzanne Leder, BA, M.Phil., CPC, COBGC
Executive Editor of the Ob-gyn Coding Alert,
Orthopedic Coding Alert, and Otolaryngology Coding Alert
Thank you so much for answering my question Suzanne and Melanie. I really appreciate it.
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