“The patient is a 47 year old with a soft tissue mass over the distal fibula. It appears to be a gouty tophus and x-rays show no bone involvement. What would be the proper code for surgical debridement/excision of this mass?”
If the soft tissue mass was located within the foot and it appeared to be a gouty tophus and it was affecting a joint, the appropriate CPT codes to consider would be the following:
CPT 28020 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint
CPT 28022 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; metatarsophalangeal joint
CPT 28024 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint
If the soft tissue mass was located in the foot and it appeared to a gouty tophus and it was not affecting a joint, the appropriate CPT codes to consider would be the following:
CPT 28039 Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater
CPT 28041 Excision, tumor, soft tissue of foot or toe, subfascial (eg. Intramuscular); 1.5 cm or greater
CPT 28043 Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm
CPT 28045 Excision, tumor, soft tissue of foot or toe subfascial (e.g. intramuscular); less than 1.5 cm
If the soft tissue mass that appeared to be a gouty tophus was located in the ankle on the lateral aspect, clearly it would be affecting the joint. The most appropriate CPT code to consider would be the following:
CPT 27620 Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body
In the above post, the soft tissue mass is located over the distal fibula and it appeared to be a gouty tophus. If the soft tissue mass was not located within the ankle, the appropriate CPT codes to consider are the following:
CPT 27618 Excision, tumor, soft tissue of leg or ankle area; subcutaneous; less than 3 cm
CPT 27619 Excision, tumor, soft tissue of leg or ankle area; subfascial (e.g. intramuscular); less than 5 cm
This is my opinion.
Michael G. Warshaw
DPM, CPC
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