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need guidance on coding ASAP

louise Posted Mon 18th of March, 2019 12:50:13 PM
Pre-OP Diagnosis: Keloid scar Post-OP Diagnosis: Keloid scar   Was there a significant difference between the Pre and Post Op Dx? No   Procedure(s): EXCISION MASS Surgeons: Surgeon(s) and Role:    * Wisecarver, Ian Richard, MD - Resident Assisting    * Villanueva, Nathaniel Leon, MD - Resident Assisting    * Vu, David Dai, MD,DDS - Resident Assisting    * Pezeshk, Ronnie Aaron, MD - Resident Assisting    * Nevin, Julia, PA-C - Resident Assisting    * Zhang, Andrew Yuan, MD - Primary    * Garibay, Maycie Mayfield, PA-C - Resident Assisting Primary Surgeon: Zhang, Andrew Yuan, MD   Anesthesia: General         EXCISION mass cpt code used11426, 11406 & interm . repair four keloids were injected with 1% lidocaine and epinephrine for a total of 27 cc. The inferior suprapubic keloid was excised using 15 blade scalpel and was sent for pathology, the subsequent defect measured 5x2 cm. Electrocautery was used to achieve hemostasis. superior suprapubic keloid which was excised using 15 blade scalpel and was sent to pathology, the subsequent defect measure 7x3cm. Electrocautery was used to obtain hemostasis. scrotal keloid which was excised using a 15 blade scalpel, the subsequent defect measured 4x2 cm. Electrocautery was used to obtain hemostasis. left scrotal keloid which was excised using 15 blade scalpel, the subsequent defect measured 7x6cm. Electrocautery was used to obtain hemostasis. defects were closed using interrupted, buried deep dermal 3-0 monocryl sutures and running 4-0 subcuticular suture.
SuperCoder Answered Tue 19th of March, 2019 07:35:00 AM

Hi,

 

(A). As per the coding guidelines, code the diagnosis for which the surgery was performed. If the post-operative diagnosis is known to be different from the pre-operative diagnosis at the time the diagnosis is confirmed, select the post-operative diagnosis for coding, since it is the most definitive.

 

(B) As per the above mentioned documentation, physician has performed excision of keloid scar at 4 different locations i.e 2 excisions at suprapubic region and 2 excision at scrotal area with intermediate repair. Each lesion removal will be coded separately; remember to report the longest excision first, as it is the only one that does not face a pay reduction for multiple procedures.

 The excision code includes simple closure, i.e., in a single layer. Intermediate or complex repair is coded separately.

 

On the claim, report the following:

11426 (for 7x6 cm excision of scrotal keloid)

11406 – 51 (for 7x3 cm excision of superior suprapubic keloid)

11406 – 51,59 (for 5x2 cm excision of superior suprapubic keloid)

11426 – 51,59 (for 4x2 cm excision of scrotal keloid)

12034 (Intermediate repair for suprapubic keloid)

12044 (Intermediate repair for scrotal keloid)

 

Note: Modifier 51 (Multiple procedures) appended to show that the excisions were separate.

 

Thanks

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