Laura Posted Thu 16th of November, 2017 12:11:37 PM
Would codes 56740 and 53260 be appropriate to use for the following documentation?
"First excise the periurethral cyst which was just lateral on the left side of the urethral meatus. The area was infiltrated with lidocaine with epinephrine. A scalpel and used to excise the cyst and the underlying mucosa. It was fairly vascular site cauterized the base with a Bugbee electrode. I then closed the tissue with a running 4-0 chromic. I then excised the labial cysts were on the patient's right. There was 1 large system was a 2nd smaller cyst below that and I elected to excise both of these. I made an incision through the skin over the cyst after infiltrating it again with lidocaine with epinephrine. The cyst was readily visible and I dissected out. He had a benign appearance. There is no significant vascular supply. Performed a similar procedure on the sole of the smaller cyst. The smaller cyst looked more like a sebaceous cyst. Both incisions were then closed with 4-0 Monocryl running."
SuperCoder Answered Fri 17th of November, 2017 05:56:21 AM
The appropriate codes are 53260 (Excision of periurethral cyst) and 11420-11426 codes for excision of labial cyst. CPT 53260 (Excision or fulguration; urethral polyp(s), distal urethra) coded correctly because surgeon is excising the cyst from the urethral meatus and urethral meatus is distal part of the urethra.
CPT 56740 is not appropriate code for labial cyst excision, as it is used for ">Excision of Bartholin's gland or cyst". As per operative report he made an incision through the skin over the cyst, so the labial cyst removal code would be used from 11420-11426 code series.