Forum - Questions & Answers

Nov 2nd, 2012 - lmoore

coding for injection

Hi I am a new medical coding student. I have a case study with the following question.
The patient is here to see us in follow-up for a keloid that was excised from his neck in November of last year. He believes that it's coming back. He does have a recurrence of the keloid on the superior portion of the scar. Since the keloid is still small, the options of an injection or radiation to the area were discussed. It was agreed that our next course should be a Kenalog injection. The risks associated with the procedure were discussed with the patient. Informed consent was obtained. The area was infiltrated with 1.5 cc of medication. This was a mixture of 1 cc of 40-mg Kenalog and 0.5 cc of 1% lidocaine with epinephrine. He tolerated the procedure well. What CPT(r) and ICD-9-CM code(s) should be reported?
I am unsure as to what code to use for the injection of the keloid. I have coded the kenalog as J3301x4, and used the ICD-9-CM code 701.4 for the scar.
Thanks for any help!

Nov 5th, 2012 - tdidier 6 

re: coding for injection

I looked for injection in the CPT® and injecting a skin lesion takes you to 11900-11901. I looked up 'lesion' to see if the keloid would be considered a lesion. It is defined as any pathological or traumatic discontinuity of tissue or loss of function of a part. I think 11900 would work.



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