Bone mass excision

Good morning everyone!
I need a CPT code for a pre-cert. I'm thinking 27635 or 27640... Any thoughts?

Here is the MRI report:

It is 2cm x 1.5 cm. And the MRI says:

There is a fluid collection measuring 8.3 x 5.2 x 18.1 mm along the medial aspect of the tibial shaft with enhancing margin.

This could represent abscess . Cystic neoplasm cannot be completely excluded but the wall is thin and not suggestive of a

necrotic tumor. There is a small amount of edema in subcutaneous tissues near the mass.

This would probably be amenable to aspiration for culture under ultrasound guidance if desired.

I'm thinking 27635 or 27640... Any thoughts?

Jill Smithers, CPC, CEMC
Physician Coder III
Ortho, WMC IPG
828.719.7752
Appalachian Regional Healthcare System

Comments

  • edited May 2017
    looks and reads to be more of 27635 - but it also states that they might
    just do an aspiration which could be 20615. Since this is a precert you
    will need more information from the surgeon if they plan to remove radically
    or curettage or aspiration/injection

    Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR
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