Lesions, and Masses, and Tumors Oh My!!

Lesions, and Masses, and Tumors Oh My!! Presented by: Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC 1 1 CPT GUIDELINES Agenda CPT DEFINITIONS OP REPORT CASES 2 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 3 1

Malignant Primary Secondary In Situ Benign Uncertain Behavior Unspecified Behavior Diagnosis Codes 4 Mass Painful? Lipoma dermatofibroma Tumor Pathology Report Cyst Type Melanoma Melanoma In Situ Diagnosis Codes 5 LESION 6 2

LIPOMA 7 MELANOMA 8 ANATOMY 9 3

The rectus sheath, an example of a fascia 10 11 11 12 12 4

13 2010 Changes To 20000 Code Set 41 new codes 53 revised codes 7 deleted codes New guidelines for soft tissue and bone tumors 14 CPT-MUSCULOSKELETAL Soft Tissue Tumors About 9000/yr 1% adults tumors 15% kids tumors 10% on trunk 13% visceral 43% extremities (mostly lower) 15 15 BJ&A 2010. ALL RIGHTS RESERVED. 5

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 16 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 17 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 18 6

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 19 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 20 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 21 7

SURGICAL PHOTOS TO FOLLOW!!!! GRAPHIC!!!! 22 21011 Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 21012 2 or greater 21013 Excision, tumor, soft tissue of face or scalp, subfascial (eg, subgaleal, intramuscular); less than 2 21014 2 or greater 21016 Radical resection of tumor, soft tissue of face or scalp, 2 or greater 23 CPT MusculoskeletaL 21555 Soft tissue, subcutaneous, neck/anterior thorax less than 3 #21552 3 or greater 21556 Soft tissue, subfascial, neck/anterior thorax less than 5 # 21554 5 or greater 21557 Radical resection soft tissue neck/anterior thorax less than 5 21558 5 or greater 24 8

21930 Soft tissue back/flank, subcutaneous less than 3 21931 3 or greater 21932 Soft tissue back/flank, subfascial less than 5 21933 5 or greater 21935 Radical resection soft tissue back/flank less than 5 21936 5 or greater 25 22900 Soft tissue abdominal wall, subfascial less than 5 22901 5 or greater 22902 Soft tissue abdominal wall, subcutaneous less 3 22903 3 or greater 22904 Radical resection soft tissue abdominal wall less than 5 22905 5 or greater 26 23075 Soft tissue shoulder area, subcutaneous less than 3 23071 3 or greater 23076 Soft tissue shoulder area, subfascial less than 5 #23073 5 or greater 23077 Radical resection soft tissue shoulder area less than 5 23078 5 or greater 27 9

24075 Soft tissue upper arm/elbow area subcutaneous less than 3 #24071 3 or greater 24076 Soft tissue upper arm/elbow area subfascial less than 5 #24073 5 or greater 24077 Radical resection soft tissue upper arm/elbow area less than 5 #24079 5 or greater 28 25075 Soft tissue forearm/wrist area subcutaneous less than 3 #25071 3 or greater 25076 Soft tissue forearm/wrist area subfascial less than 3 #25073 3 or greater 25077 Radical resection soft tissue forearm/wrist area less than 3 25078 3 or greater 29 26115 Soft tissue hand/finger subcutaneous less than 1.5 #26111 1.5 or greater 26116 Soft tissue hand/finger subfascial less than 1.5 #26113 1.5 or greater 26117 Radical resection soft tissue hand/finger less than 3 26118 3 or greater 30 10

27047 Soft tissue pelvis/hip area subcutaneous less than 3 #27043 3 or greater 27048 Soft tissue pelvis/hip area subfascial less than 5 #27045 5 or greater 27049 Radical resection soft tissue pelvis/hip area less than 5 #27059 5 or greater 31 27327 Soft tissue thigh/knee area subcutaneous less than 3 #27337 3 or greater 27328 Soft tissue thigh/knee area subfascial less than 5 #27339 5 or greater #27329 Radical resection soft tissue thigh/knee area less than 5 27364 5 or greater 32 27615 Radical resection soft tissue leg/ankle less than 5 27616 6 or greater 27618 Soft tissue leg/ankle subcutaneous less than 3 #27632 3 or greater 27619 Soft tissue leg/ankle subfascial less than 5 #27634 5 or greater 33 11

28043 Soft tissue foot/toe subcutaneous less than 1.5 #28039 1.5 or greater 28045 Soft tissue foot/toe subfascial less than 1.5 #28041 1.5 or greater 28046 Radical resection soft tissue foot/toe less than 3 28047 3 or greater 34 Coding Op Reports CODING MUSTS Tumor, mass, lesion, or else? Depth (subcutaneous, subfascial, bone) Size Watch for the out of sequence codes 35 GRAPHIC VIDEO NEXT!!!! 36 12

PROCEDURE PERFORMED: Excision mass, behind right ear with excised diameter of 8 mm and complex repair 1.8 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: 37 PROCEDURE PERFORMED: Excision of submuscular lipoma, forehead with excised diameter of 1.2 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): 38 PROCEDURE PERFORMED: Excision of cyst, right posterior ear with excised diameter of 1.2 and complex repair of 2.3 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): 39 13

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 and complex repair of a 3.2 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. 40 PREOPERATIVE DIAGNOSIS: Mass, left flank. POSTOPERATIVE DIAGNOSIS: Mass, left flank. PROCEDURE PERFORMED: Excision mass, left flank with excised diameter 4-. 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. 41 POSTOPERATIVE DIAGNOSIS: PROCEDURE PERFORMED: 8.7- wound. Lipoma, deep left flank Excision, lipoma, deep left flank with excised diameter of a 11.5- and complex repair of 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. 42 14

PREOPERATIVE DIAGNOSIS: mass, posterior neck. POSTOPERATIVE DIAGNOSIS: mass, posterior neck. PROCEDURE PERFORMED: Excision of subcutaneous mass posterior neck with excised diameter of 2.2-. 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. 43 THANK YOU!! Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC 44 Resources Gray s Anatomy, 1918 CPT Professional Edition 2011 Vesalius 45 15