JENNIFER Posted Thu 23rd of February, 2017 17:48:13 PM
op report reads "The underlying epidermal inclusion cyst was dissected away from the surrounding soft tissue. There were multiple pockets of abscess within the epidermal inclusion cyst and purulent material outside of the epidermal inclusion cyst. The epidermal cyst was excised.
I then explored the wound and some loculated areas of abscess were taken down. Once I felt the the loculations had been completely taken down and no undrained abscess was left in place, the wound was irrigated and dried. Multiple areas of bleeding were addressed.
Based in this documentation is it appropriate to bill cpt codes 11046-59 and 10061.
JENNIFER Posted Thu 23rd of February, 2017 18:02:42 PM
Actually it should be 11406-59, 10061
SuperCoder Answered Mon 27th of February, 2017 08:28:32 AM
Please provide additional information in context to your above documentation.
1. Anatomical location of cyst.
2. Size of the lesion excised.
The above information would help us in determining the appropriate code.
JENNIFER Posted Thu 02nd of March, 2017 11:08:12 AM
Anatomical location is on the back, and the size of lesion was 7-8 cm
SuperCoder Answered Fri 03rd of March, 2017 07:04:17 AM
As per above mentioned documentation the appropriate CPT code will be 11406 only.