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Excision - Postop Abdominal wall wound sinus tract (3.5 cm)/FB

Tanesha Posted Mon 28th of October, 2019 10:35:39 AM
I came up with and unlisted code (49999 (FB removal) and 22903) but not sure if correct. Op excerpt: Methylene blue was placed into the sinus tract using a Q-tip. An elliptical incision was made around the sinus tract. A sharp dissection carried the incision down to the abdominal wall fascia, where a retained Prolene suture knot was identified. This was removed in total. Undermining performed with complex closure. For the dxs, I have L76.82 and M79.5. Agree?
SuperCoder Answered Tue 29th of October, 2019 10:34:34 AM

Hi,

Our team is working on it. We will get back to you soon.

Tanesha Posted Tue 29th of October, 2019 10:55:22 AM
Will this be later today by chance?
Tanesha Posted Tue 29th of October, 2019 23:50:44 PM
Per the path, this was a cyst, fibrosis and inflammation. I'm now thinking 20520 or 20525 would be a better choice for the FB.
SuperCoder Answered Wed 30th of October, 2019 03:58:45 AM

Hi,

 

CPT 22903 is not an appropriate code as it is used for tumor excision and as per operative report surgeon is not removing tumor.

CPT 49999 is also not an correct code as it is used when surgeon perform procedure on abdomen, peritoneum and omentum, whereas in operative report surgeon is working on abdominal wall fascia.

CPT does not contain a specific code for FBR from the abdomen, you must select from between 20520 (Removal of foreign body in muscle or tendon sheath; simple) or 20525 (... deep or complicated). In above mentioned report, the surgeon has performed sharp dissection carried the incision down to the abdominal wall fascia which is deep, so the appropriate CPT code will be 20525.

 

Thanks

Tanesha Posted Wed 30th of October, 2019 12:11:01 PM
Thanks for your response. I do understand that this isn't a tumor, but 3M leads to 22903 as the description is soft tissue lesion/tumor (per 3M) which is why I was thinking it was 22903, but since a FB was removed as well, I agree with only the removal of FB. Thanks again
SuperCoder Answered Fri 01st of November, 2019 01:14:46 AM

Thank you, happy to help.

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