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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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CPT® Musculoskeletal
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
• Simple & Intermediate repair bundled
• 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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CPT® Musculoskeletal
Radical resection of soft tissue tumors
• Simple & Intermediate repair bundled
• 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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CPT® Musculoskeletal
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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CPT® Musculoskeletal
Radical resection of bone tumors
• Simple & Intermediate repair bundled
• 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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CPT® Musculoskeletal
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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CPT® Musculoskeletal
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
21014 2 cm or greater
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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CPT® Musculoskeletal
21930 Soft tissue back/flank, subcutaneous less than 3
cm
21931 3 cm or greater
21932 Soft tissue back/flank, subfascial less than 5 cm
21933 5 cm or greater
21935 Radical resection soft tissue back/flank less than 5
cm
21936 5 cm or greater
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CPT® Musculoskeletal
22900 Soft tissue abdominal wall, subfascial less than 5
cm
22901 5 cm or greater
22902 Soft tissue abdominal wall, subcutaneous less 3 cm
22903 3 cm or greater
22904 Radical resection soft tissue abdominal wall less
than 5 cm
22905 5 cm or greater
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CPT® Musculoskeletal
23075 Soft tissue shoulder area, subcutaneous less than
3 cm
23071 3 cm or greater
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
23078 5 cm or greater
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CPT® Musculoskeletal
24075 Soft tissue upper arm/elbow area subcutaneous less than 3 cm
#24071 3 cm or greater
24076 Soft tissue upper arm/elbow area subfascial less than 5 cm
#24073 5 cm or greater
24077 Radical resection soft tissue upper arm/elbow area less than 5 cm
#24079 5 cm or greater
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CPT® Musculoskeletal
25075 Soft tissue forearm/wrist area subcutaneous less
than 3 cm
#25071 3 cm or greater
25076 Soft tissue forearm/wrist area subfascial less than
3 cm
#25073 3 cm or greater
25077 Radical resection soft tissue forearm/wrist area
less than 3 cm
25078 3 cm or greater
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CPT® Musculoskeletal
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
26118 3 cm or greater
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CPT® Musculoskeletal
27047 Soft tissue pelvis/hip area subcutaneous less than
3 cm
#27043 3 cm or greater
27048 Soft tissue pelvis/hip area subfascial less than 5
cm
#27045 5 cm or greater
27049 Radical resection soft tissue pelvis/hip area less
than 5 cm
#27059 5 cm or greater
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CPT® Musculoskeletal
27327 Soft tissue thigh/knee area subcutaneous less
than 3 cm
#27337 3 cm or greater
27328 Soft tissue thigh/knee area subfascial less than 5
cm
#27339 5 cm or greater
#27329 Radical resection soft tissue thigh/knee area less
than 5 cm
27364 5 cm or greater
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CPT® Musculoskeletal
27615 Radical resection soft tissue leg/ankle less than 5
cm
27616 6 cm or greater
27618 Soft tissue leg/ankle subcutaneous less than 3 cm
#27632 3 cm or greater
27619 Soft tissue leg/ankle subfascial less than 5 cm
#27634 5 cm or greater
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CPT® Musculoskeletal
28043 Soft tissue foot/toe subcutaneous less than 1.5 cm
#28039 1.5 cm or greater
28045 Soft tissue foot/toe subfascial less than 1.5 cm
#28041 1.5 cm or greater
28046 Radical resection soft tissue foot/toe less than 3
cm
28047 3 cm or greater
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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