I’ve a case where:

Operative report mentions Wrist volar/antebrachial fascia cyst and H&P report mentions "It was a source of local discomfort left wrist". The patient also has Carpal tunnel syndrome.

The surgeon made an incision for CTR procedure and then extended it proximally to gain access to the cyst (0.5 cm) which was within the antebrachial fascia, removed it and submitted to pathology. Then, he went on and released the carpal tunnel.

Pathology report mentions: benign fibroadipose tissue

Now, since the path report doesn’t mention cyst or any other abnormal finding (let alone tumor) I’m not sure what I should code for Dx and CPT. I’ve narrowed it down to the following:

1. Dx – pain wrist left; CPT – Biopsy, soft tissue of wrist; deep
2. Dx – other disease fascia; CPT – Excision, tumor, soft tissue wrist, subfascial; less than 3 cm

I’m more inclined towards the first option as there is no abnormal pathology.

Could anybody help me on this?

Thanks!

Amber