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General Surgery Coding Alert

You Be the Coder:
Look to Musculoskeletal Codes for Lipoma

Question: Our surgeon excised a 3.4 cm lipoma in the sacral region. Should I choose a code from the benign (114xx) or malignant (116xx) lesion excision codes? Or should we report 49215? Kansas Subscriber Answer: None of the codes you mentioned would be appropriate for a sacral lipoma excision. Instead, you should report a soft tissue tumor code based on the location, depth, and size of the lipoma. Here's why: Lipomas are benign fatty tumors that generally occur blow the skin. You should not choose a code from the integumentary system to describe a lipoma excision. If the surgeon documents a tumor excision that is only a full-thickness dermal mass from the sacral region, then you would choose 11404 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm) or 11604 (Excision, malignant lesion including margins, trunk, arms, or [...]