what are the CPT and ICD-9-CM codes for following question?
"this is a pleasant female who comes in with a soft tissue lesion in the left flank over what appeared to be a spigelian hernia site as well. However, it was not reducible and did not appear to be consistent with a hernia. consequently, the procedure, risks, benefits, and alternatives of excision of this lesion were discussed with the patient, and she understood and wished to proceed with the excision. Operative findings were a Large soft tissue lesion measuring about 6 cm in greatest dimension. Operative Procedure: the patient was brought into the operation room after informed consent was obtained. the patient then underwent sedation with a sterile prep and drape. we then anesthetized with 1% lidocaine with epinephrine and sodium bicarbonate, made a 4-cm incision, and used sharp dissection to dessect circumferentially around this soft tissue lesion, being careful to make sure that we were not entering any kind of hernia sac secondary to spigelian hernia. As we continued to dissect circumferentially around it without sharp dissection, it was noted that it did go down to a muscle, but no evidence of hernia was identified. the lesion was excised in its entirety, and electrocautery was used to control hemostasis. we then irrigated with saline solution an closed the subcutaneous tissue with 3-0 Vicryl interrupted and running sutures. we then used 4-0 vicryl sutures to close the skin a subcuticular fashion. benzoin and steristrips were then applied. blood loss was minimal. the patient tolerated the procedure well and remained in stable condition throughout the prcedure. Provide the CPT Code(s) and ICD-9-CM code(s)."
CPT code: 21931-LT Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater
ICD-9-CM code: 215.7 Trunk, unspecified; back NOS; flank NOS
11555156
To determine the CPT code(s) and ICD-9-CM code(s) for the given scenario, we need to identify the key details and procedures mentioned in the report.
From the description, we can identify the following key details:
1. Soft tissue lesion in the left flank, potentially associated with a Spigelian hernia site.
2. Non-reducible and inconsistent with a hernia.
3. Excision of the lesion performed.
4. Operative findings: A large soft tissue lesion measuring about 6 cm.
5. Procedure details: Sedation, sterile prep and drape, anesthetization with lidocaine with epinephrine and sodium bicarbonate, incision, sharp dissection, excision of the lesion, electrocautery for hemostasis, irrigation, closure of subcutaneous tissue with Vicryl sutures, closure of skin with Vicryl sutures, application of benzoin and steristrips, minimal blood loss, good patient tolerance, and stable condition throughout the procedure.
Now let's find the appropriate codes based on the details mentioned.
CPT code(s):
Based on the information provided, the most likely CPT code for this scenario is 11406 - Excision, benign lesion, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips; lesion diameter over 4.0 cm, because the lesion measured about 6 cm.
ICD-9-CM code(s):
Unfortunately, the ICD-9-CM code(s) cannot be provided accurately since it requires information about the specific diagnosis for the soft tissue lesion. Without more detailed information about the nature of the lesion, such as a pathology report or specific clinical diagnosis, it is not possible to determine the appropriate code(s). It is important to consult with a healthcare professional or a medical coder who can assess the patient's condition and provide the accurate ICD-9-CM code(s) based on the diagnosis.
Please note that as of October 1, 2015, the ICD-10-CM code set has replaced ICD-9-CM codes for diagnoses, so it is advisable to use ICD-10-CM codes for accurate and up-to-date classification.
To finalize the billing and coding process, it is recommended to consult with a qualified medical coder or healthcare professional who can review the complete medical documentation and assign the accurate CPT and ICD-10-CM codes for proper reimbursement and documentation purposes.