Hi, one of my docs (internal medicine), performed removal of cyst on a patient and insurance denied so the patient has been calling to see if we can change the cpt. Here is the very brief procedure note:
"Under sterile conditions and 2% xylocaine, I incised the cyst sharply. The sample was sent to pathology. I closed the skin with 3 sutures of 4-0 nylon. Neosporin was applied and some nonstick dressing was used."
Path report states epidermal inclusion cyst.
I used 10040 because in the cpt book, if you go to removal, cyst, it lists 10040. Or should this be an excision code 114xx ? Now he is saying it should have said excision not incision. The date of this goes all the way back to Jan of 2017.
Thanks for any input!