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Code This!

Scenario Week of February 06, 2006:
View Current Scenario

Assign the appropriate ICD-9-CM diagnosis code and CPT® procedure codes to the following scenario:

Preoperative diagnosis: Cyst of the right tibia
Postoperative diagnosis: Cyst of the right tibia
Operation: Curettage of cyst of tibia and bone graft, separate incision
Anesthesia: General
Complications: None

A 19-year-old female presents for curettage of a cyst of her right tibia. The cyst was biopsied three weeks ago. Pathology findings were negative for malignancy.

Description of Procedure:

The patient was brought to the operating room and general anesthesia was administered. The right leg was prepped and draped in the usual manner. The incision site from the previous biopsy was again incised to provide access to the area of the cyst. There were no signs of infection or malignancy. The cyst was well corticated and had a sclerotic margin. Curettage of the cyst was performed. The area was drilled to promote blood flow into the area. With separate instruments, a separate incision was made on the proximal tibia for a bone graft. An osteotome and a curet were used to take some bone curettings. The area was irrigated and closed. The bone graft was implanted into the site which was irrigated and closed using 2-0 Dexon and 3-0 Dermalon. Marcaine was injected into the wounds for pain relief, and a posterior splint was applied. The patient tolerated the procedure well and was taken to the post-anesthesia care unit in satisfactory condition.

ICD-9-CM Diagnosis Code:
733.20 Cyst of bone (localized), unspecified

In this situation, the unspecified code is selected since the available information fails to reveal the specific type of bone lesion. To provide a more specific diagnosis code, you will have to verify the diagnosis with the pathology report and/or the surgeon.

CPT® Procedure Code:
27637 Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft)

In this situation, the bone graft is not reported separately as the graft is clearly included in the code descriptor for the primary procedure. When tissue is transplanted from one part of the body to another in the same individual, it is an autograft, as opposed to an allograft, which refers to a transplant of tissue from one person to another.

CPT is a registered trademark of the American Medical Association


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