Wiki Excision of masses-Path shows one is lymph node

[clbarry8033]

Hello, I'm hoping someone can help me with this case.

1. The patient had multiple scalp masses bilaterally, however, the patient wanted to have only the wound on her left side remove. The ones removed were #1 midline parietal area measuring 6 x 3 x 2 cm, the second was midline occipital measuring 2 x 2 x 1 cm.
2. Left occipital lobe measuring 3.5 x 2 x 2 cm. All masses were cystic in nature

The patient was taken to OR suite and placed in supine position. Following induction of general endotracheal anesthesia, administration of IV antibiotics, the patient was then repositioned prone with careful attention of padding of her pressure points throughout. The overlying masses had been marked in the preoperative holding area. These areas were then isolated, the hair over them was then trimmed. We then prepped the scalp area in the usual sterile fashion. I began first by excising the first one. This was the largest one. An elliptical incision was made around it after local anesthetic was administered. The cystic mass was then separated from the skin anteriorly and posteriorly then bilaterally and then it was tangentially taken off of the galea of the scalp. Once the specimen was then freed, it was measured and passed off and sent to pathology. There was significant oozing present. There was one small arterial bleeder, which was rendered hemostatic using electrocautery. We cauterized the majority of the bleeders, packed this area temporarily and attention was then directed to the one in the midline occipital area, in the very similar fashion, the incision was then made over this in elliptical fashion and also was then carried down to its base and then tangentially excised it too was then passed off and measured and sent to pathology. The wound was inspected for hemostasis. I then rendered hemostatic and attention at this point redirected to the one in the left posterior auricular region. This one also required a longitudinal incision over and it too was then carried down to these masses. The cystic masses were easily separated from the surrounding tissues. There was 2 masses together, we measured them to get ____ dimension between the 2 as they were connected to each other, but there were a total volume was measured for the record. We then after these were removed and also measured. We then inspected the area for hemostasis rendered hemostatic. We began first by closing the first lesion in the occipital area. This was after applying Arista hemostatic agent to the base of the wound. We then closed the skin with interrupted vertical mattress sutures of nylon. I then excised a small amount of excess skin from the initial largest parietal wound and we then again completely rendered hemostatic applied Arista and it too was closed with interrupted vertical mattress sutures of nylon and then lastly the one in the posterior auricular left occipital area was also closed with vertical mattress sutures of nylon. The area appeared to be hemostatic. We placed a sterile dry dressing. The patient tolerated the procedure, no immediate complication. She was taken to Postanesthesia Care Unit in satisfactory condition.

Path shows 1st mass (parietal area) to be squamous cell carcinoma; 2nd mass Trichilemmal (pilar) cyst; 3rd mass - lymph node

I was thinking either 21012 vs 11626 for the 1st, 11422 for the 2nd, and 11424 for the 3rd.

Additionally, should the 11424 be changed to 38500 due to the mass turning out to be a lymph node? Wasn't sure if the final path could drive that particular CPT change.
Thanks!
Chelsea

 

[HReed]

I would lean toward 11626 for the first lesion with diagnosis of C44.42 for squamous cell. Using 11422 for the 2nd lesion would be correct with diagnosis of L72.11. And I would lean toward using 11424 for the 3rd lesion with R22.0. But I would want to know why this was being excised. That could make the difference in possibly using 38500. Did the doctor suspect an enlarged or infected lymph node? Did the doctor feel there was an infection due to tenderness in the area? What was the patient's complaint about this area? Has the patient had this problem previously? These excisions can also be coded based on the doctor's impression of the area or discussion with the patient.

 

[xXxPARAGONxXx]

Almost sounds to me like the provider was not aware they were excising a lymph node in the posterior auricular region; almost sounds like they were under the impression they were excising cysts [only].

 

[clbarry8033]

I would lean toward 11626 for the first lesion with diagnosis of C44.42 for squamous cell. Using 11422 for the 2nd lesion would be correct with diagnosis of L72.11. And I would lean toward using 11424 for the 3rd lesion with R22.0. But I would want to know why this was being excised. That could make the difference in possibly using 38500. Did the doctor suspect an enlarged or infected lymph node? Did the doctor feel there was an infection due to tenderness in the area? What was the patient's complaint about this area? Has the patient had this problem previously? These excisions can also be coded based on the doctor's impression of the area or discussion with the patient.

Yes, provider was not aware or did not mention it was a lymph node. They were only referred to as sebaceous cysts/SC masses that have been removed in the past, in his office visits.