Diane Posted Mon 11th of March, 2019 16:38:24 PM
I need help in finding a CPT code for excision Lesion of the ankle. Patient had surgery years ago and the wound keeps opening back up and draining. Doctor said he is going to go in and cut it out and send to lab to see what it is. He doesn't know what it is, could be a draining sinus tract, he said that the lesion is about an inch long. I am looking at CPT 11043,11403, 13160. I do not see any codes that would work in the Leg (Tib Fib) ankle section. Any suggestions would be appreciated.
SuperCoder Answered Tue 12th of March, 2019 06:56:10 AM
Thank you for your question.
This limited documentation is not enough to provide the exact codes for the above-mentioned procedures. You are requested to provide a brief about the actual procedures performed.
Diane Posted Tue 12th of March, 2019 15:00:39 PM
The only order that the doctor wrote said excision lesion. I asked him if it was a cyst, tumor, or what it was, he said he did not know for sure what it was it is in an area where he had done surgery years ago and every once in awhile over the years the incision will open back up again and start draining. So he said he was going to cut it out and send to the lab to see what it is, he stated it is probably draining sinus tract.
SuperCoder Answered Wed 13th of March, 2019 04:29:26 AM
As per the above statement CPT code 11400-11406 seems appropriate for the order that doctor has provided. If the provider is planning excision at skin level than CPT code 11400-11406 would be appropriate. Choose the correct code from 11400-11406 by adding the greatest clinical diameter of the apparent lesion and the margins. Each anatomical group contains lesion excision sizes ranging from small to large lesions. CPT's excision sizes, including margins, are based on the physician's measurements.
Note: The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of benign lesions requiring more than simple closure, ie, requiring intermediate or complex closure, report 11400-11446 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes
Hope this Helps!