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coding lipoma

Anil Posted Mon 23rd of May, 2011 14:23:50 PM

My Surgeon performed multiple procedures during the same surgery-

1. Excision of large soft tissue mass, possible lipoma, left side upper back 20X10 cm.
2. Excision of soft tissue mass, possible lipoma, right side upper back 8X5.5 cm.
3. Excision of excess skin and subcutaneous tissue upper back, left side trunk, total 10X2.5 cm
4. Complex layer closure of procedure 3.

I am thinking of coding
1. 21933 LT
2. 21933 59 RT
3. 15839
4. 13101 51
5. 13102 times 3units

Please let me know if this will work. Patient has Aetna Medicare HMO. For procedure 1 and 2 should I just combine and use Bilateral modifier 50 and make the unit as 2?
Thanks in advance for your help.

SuperCoder Answered Mon 23rd of May, 2011 14:55:15 PM

Yes, you could bill like this and of course you could combine both procedures 1&2 with 50 or 2, but remember one thing, you should maintain the code sequence while you are submitting the claim. As 13101 is a column 2 code of 21933 as per latest CCI version 17.1, would be better to append 59 in column 2 code (13101) rather than 51. You should use 59 if the service is performed at a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. So here you could bill like this:
15839
21933-50 or 2 whatever
13101-59
13102x3
Hope this helps..

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