lesions, and masses, and tumors oh my!! -...

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Lesions, and Masses,

and Tumors – Oh My!!

Presented by:

Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC

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Agenda

• CPT® GUIDELINES

• CPT® DEFINITIONS

• OP REPORT CASES

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Definitions

• Cyst - a closed sac having a distinct membrane and

developing abnormally in a cavity or structure of the

body

• Dermatofibroma - a benign, chiefly fibroblastic nodule of

the skin found especially on the extremities of adults

• Lipoma - a tumor of fatty tissue

• Neoplasm - a new growth of tissue serving no

physiological function

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Diagnosis Codes

• Malignant

– Primary

– Secondary

– In Situ

• Benign

• Uncertain Behavior

• Unspecified Behavior

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Diagnosis Codes

• Mass

– Painful?

• Lipoma

– dermatofibroma

• Tumor

– Pathology Report

• Cyst

– Type

• Melanoma

– Melanoma In Situ

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LESION

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LIPOMA

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MELANOMA

ANATOMY

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The rectus sheath, an

example of a fascia

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CPT® Musculoskeletal

2010 Changes To 20000 Code Set

• 41 new codes

• 53 revised codes

• 7 deleted codes

• New guidelines for soft tissue and bone tumors

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CPT-MUSCULOSKELETAL

Soft Tissue Tumors

• About 9000/yr

• 1% adults tumors

• 15% kids tumors

• 10% on trunk

• 13% visceral

• 43% extremities (mostly lower)

BJ&A 2010. ALL

RIGHTS RESERVED.

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Excision of subcutaneous soft tissue tumors

• Simple & Intermediate repair bundled

• Confined to subcutaneous tissue below the skin, but

above the deep fascia

• Usually benign

• Code selection based on location and size of tumor

• Size determined by greatest diameter of tumor plus

most narrow margin necessary for excision

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CPT® Musculoskeletal Excision of fascial or subfascial soft tissue tumors


• Confined to the tissue within or below the deep fascia, but not

involving the bone

• Usually benign and often intramuscular

• Code selection based on location and size of tumor

• Size determined by greatest diameter of tumor plus most

narrow margin necessary for excision

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Radical resection of soft tissue tumors


• Involves resection of tumor with wide margins of

normal tissue

• May be confined to a specific layer, may involve

removal of tissue from one or more layers

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Radical resection of soft tissue tumors

• Most common for malignant tumors or very

aggressive benign tumors

• Code selection based on location and size of

tumor

• Size determined by greatest diameter of tumor

plus most narrow margin necessary for excision

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Radical resection of bone tumors


• Involves resection of tumor with wide margins of normal tissue

• May require removal of entire bone if tumor growth is extensive

• Most common for malignant tumors or very aggressive benign tumors

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Radical resection of bone tumors

• If surrounding soft tissue is removed during these

procedures, radical resection of soft tissue tumor

codes should not be reported separately (bundled)

• Code selection based on location of tumor, NOT size

or whether tumor is benign, malignant, primary, or

metastatic

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SURGICAL PHOTOS TO

FOLLOW!!!!

GRAPHIC!!!!

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21011 Excision, tumor, soft tissue of face or scalp,

subcutaneous; less than 2 cm

21012 2 cm or greater

21013 Excision, tumor, soft tissue of face or scalp,

subfascial (eg, subgaleal, intramuscular); less than

2 cm


21016 Radical resection of tumor, soft tissue of face or

scalp, 2 cm or greater

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CPT® MusculoskeletaL

21555 Soft tissue, subcutaneous, neck/anterior thorax less than 3cm

#21552 3cm or greater

21556 Soft tissue, subfascial, neck/anterior thorax less than 5cm

# 21554 5cm or greater

21557 Radical resection soft tissue neck/anterior thorax less than 5cm

21558 5cm or greater

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21930 Soft tissue back/flank, subcutaneous less than 3

cm


21932 Soft tissue back/flank, subfascial less than 5 cm


21935 Radical resection soft tissue back/flank less than 5

cm


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22900 Soft tissue abdominal wall, subfascial less than 5

cm


22902 Soft tissue abdominal wall, subcutaneous less 3 cm


22904 Radical resection soft tissue abdominal wall less

than 5 cm


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23075 Soft tissue shoulder area, subcutaneous less than

3 cm


23076 Soft tissue shoulder area, subfascial less than 5

cm

#23073 5 cm or greater

23077 Radical resection soft tissue shoulder area less

than 5 cm


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24075 Soft tissue upper arm/elbow area subcutaneous less than 3 cm


24076 Soft tissue upper arm/elbow area subfascial less than 5 cm


24077 Radical resection soft tissue upper arm/elbow area less than 5 cm


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25075 Soft tissue forearm/wrist area subcutaneous less

than 3 cm


25076 Soft tissue forearm/wrist area subfascial less than

3 cm


25077 Radical resection soft tissue forearm/wrist area

less than 3 cm


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26115 Soft tissue hand/finger subcutaneous less than 1.5

cm

#26111 1.5 cm or greater

26116 Soft tissue hand/finger subfascial less than 1.5 cm

#26113 1.5cm or greater

26117 Radical resection soft tissue hand/finger less than

3 cm


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27047 Soft tissue pelvis/hip area subcutaneous less than

3 cm


27048 Soft tissue pelvis/hip area subfascial less than 5

cm


27049 Radical resection soft tissue pelvis/hip area less

than 5 cm


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27327 Soft tissue thigh/knee area subcutaneous less

than 3 cm


27328 Soft tissue thigh/knee area subfascial less than 5

cm


#27329 Radical resection soft tissue thigh/knee area less

than 5 cm


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27615 Radical resection soft tissue leg/ankle less than 5

cm


27618 Soft tissue leg/ankle subcutaneous less than 3 cm


27619 Soft tissue leg/ankle subfascial less than 5 cm


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28043 Soft tissue foot/toe subcutaneous less than 1.5 cm


28045 Soft tissue foot/toe subfascial less than 1.5 cm


28046 Radical resection soft tissue foot/toe less than 3

cm


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Coding Op Reports

CODING MUSTS

• Tumor, mass, lesion, or else?

• Depth (subcutaneous, subfascial, bone)

• Size

• Watch for the out of sequence codes

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GRAPHIC VIDEO

NEXT!!!!

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PROCEDURE PERFORMED: Excision mass, behind right ear with

excised diameter of 8 mm and complex repair 1.8 cm wound.

…… I incised the ellipses as I had drawn it and then dissected down to

the mass which was found deep to the superficial fascia of her neck. It

appeared to be a small lipoma or possibly a lymph node. Hemostasis

achieved using the Bovie cautery. I was able to remove the mass

completely. Defects were created at each end of the wound to optimize

the primary repair because thus I considered a complex repair. The

wound was closed in layers using 4-0 Monocryl and 5-0 Prolene. Loupe

magnification was used. The patient tolerated the procedure well.

Pathology Report: Inflamed lymph node

CPT Code(s):

ICD-9-CM Code:

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PROCEDURE PERFORMED: Excision of submuscular lipoma, forehead with

excised diameter of 1.2 cm and layered repair.

DESCRIPTION OF PROCEDURE: …..An incision was made as drawn and

then dissection was carried down to the frontalis muscle, which was separated

in direction of its fibers and a submuscular mass was encountered and

appeared to be a lipoma. It was dissected away from its attachments to the

overlying muscle and the underlying periosteum. Once the mass was

completely removed, hemostasis was achieved using the Bovie cautery. The

frontalis was closed using 4-0 Monocryl and the skin closed in layers using 4-0

Monocryl and 6-0 Prolene. Loupe magnification was used. The patient tolerated

the procedure well.

PATHOLOGY REPORT: Lipoma

CPT Code(s):

ICD-9-CM Code(s):

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PROCEDURE PERFORMED: Excision of cyst, right posterior ear with excised

diameter of 1.2 cm and complex repair of 2.3 cm wound.

DESCRIPTION OF PROCEDURE: ... I excised the cyst as drawn and down

well into the subcutaneous fat. I did feel like I was able to be the cyst

completely removed. Hemostasis was achieved with Bovie cautery. Defects

were created at each end of the wound to optimize the primary repair in

addition to undermining, and because of this, I considered a complex repair.

The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene. Loupe

magnification was used. The patient tolerated the procedure well.

PATHOLOGY REPORT: Epidermal Inclusion Cyst

CPT code(s):

ICD-9-CM code(s):

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PREOPERATIVE DIAGNOSIS: Recurrent lipoma right cheek.

POSTOPERATIVE DIAGNOSIS: Recurrent lipoma right cheek.

PROCEDURE PERFORMED: Excision recurrent lipoma right cheek with

excised diameter of 2.5 cm and complex repair of a 3.2 cm wound.

SPECIMENS: Mass right cheek for permanent pathology.

INDICATIONS FOR SURGERY: The patient is a 56-year-old man who has a mass of his right cheek.

He tells me that he had a mass, which sounds like a lipoma removed in the past, so this has recurred.

I marked the area for its outline and I drew my planned incision to give him the best idea of the resulting scar.

The patient observed these markings in a mirror, so he could understand the surgery and agree on the

location and we proceeded.

DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The

face prepped and draped in sterile fashion. I excised the skin as drawn and dissected

down into the subcutaneous space and this mass, which appeared to be a lipoma,

became obvious. I thus dissected the mass from its surrounding attachments to the

subcutaneous fat. The underlying SMAS and scar as the area was quite scarred. I

did feel like I was able to get the mass completely removed. This patient’s nerve

function was intact after the procedure. Meticulous hemostasis was achieved using

the Bovie cautery. A defect was created at the lower end of the wound to optimize

the primary repair and because of this, I considered a complex repair and the wound

was closed in layers using 4-0 Monocryl and 6-0 Prolene. Loupe magnification was

used. The patient tolerated the procedure well.

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PREOPERATIVE DIAGNOSIS: Mass, left flank.

POSTOPERATIVE DIAGNOSIS: Mass, left flank.

PROCEDURE PERFORMED: Excision mass, left flank with excised diameter 4-

cm.

SPECIMEN: Mass, left flank appears to be a lipoma.

INDICATIONS FOR SURGERY: The patient is a 27-year-old white woman with a

mass of the left flank, I marked the area for incision. She observed the markings,

so she understand the surgery and agree on location and we proceeded.

DESCRIPTION OF PROCEDURE: With the patient on the right side the area

infiltrated with local anesthetic. The flank prepped and draped in sterile

fashion. I incised the skin overlying the mass as drawn and dissection

down to the mass was appeared to be a lipoma. We were able to

complete the removal of the lipoma. Meticulous hemostasis achieved

using the Bovie cautery. The wound was closed in two layers using 3-0

Monocryl and 4-0 Monocryl. Loupe magnification was used. The patient

tolerated the procedure well.

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POSTOPERATIVE DIAGNOSIS: Lipoma, deep left flank PROCEDURE PERFORMED: Excision, lipoma, deep left flank with excised diameter of a 11.5-cm and complex repair of

8.7-cm wound.

INDICATIONS FOR SURGERY:

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room.

Bilateral pneumatic compression stockings were worn throughout the procedure.

General anesthesia was induced. IV Clindamycin was given. The abdomen and flank

prepped and draped in sterile fashion. I infiltrated the planned incision with a local

anesthetic and incised the skin and went through Scarpa’s fascia and there

encountered this large lipoma. I began dissection away from its surrounding

subcutaneous attachments and actually went into her external oblique muscle. It was

dissected away from the muscle. I did feel we were able to get it completely

removed. Meticulous hemostasis was achieved using a Bovie cautery. I repaired the

most superficial layer of the external oblique including its fascia, which was quite

attenuated that far laterally with 0 PDS suture and then I used a 3-0 Monocryl to

approximate Scarpa’s fascia taking the bites of the deep fascia to eliminate dead

space and because of these maneuvers, I considered a complex repair. I did create

a defect at one end of the wound to facilitate primary closure as she had a developed

a relative excessive skin once this large mass was removed and the skin was closed

in layers using 4-0 Monocryl. The patient tolerated the procedure well. A loupe

magnification was used.

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PREOPERATIVE DIAGNOSIS: mass, posterior neck.

POSTOPERATIVE DIAGNOSIS: mass, posterior neck.

PROCEDURE PERFORMED: Excision of subcutaneous mass posterior neck with excised diameter of

2.2-cm.

ANESTHESIA: Local, using 3 cc of 1% lidocaine with epinephrine.

SPECIMENS: Mass posterior neck, the specimen appeared to be a lipoma.

INDICATIONS FOR SURGERY: The patient is a 29-year-old girl with a mass on the posterior

neck. This felt to be deep under subcutaneous tissues or possibly submuscular. For this

reason, I chose to remove this here at the outpatient surgery center so we could use

cautery. I marked the area for excision and the patient observed these markings in a

mirror, so she could understand the surgery and agreed on the location and understand

the resultant scar, which I had drawn and we proceeded.

DESCRIPTION OF PROCEDURE: With the patient prone, the area was infiltrated with local

anesthetic. The neck, upper back, and shoulder prepped and draped in sterile fashion. I

incised the skin over the mass and then dissected down to this mass, which appeared to

be a lipoma. It was dissected from its subcutaneous attachments. Hemostasis was

achieved using Bovie cautery and the wound was closed in layers using 4-0 Monocryl.

Loupe magnification was used. The patient tolerated the procedure well.

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THANK YOU!!

Susan Ward, CPC, CPC-H, CPC-I, CPCD,

CEMC, CPRC

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Resources

• Gray’s Anatomy, 1918

• CPT® Professional Edition 2011

• Vesalius

lesions, and masses, and tumors oh my!! -...

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