Epidermal Inclusion Cysts and Variants

Epidermal inclusion cysts arise from a plugged follicular opening, resulting in a nodular cyst filled with cheesy malodorous keratin material. These are also commonly and incorrectly called sebaceous cysts but do not in fact contain any sebum. Unfortunately, the ICD code for these cysts is named “sebaceous cyst” so you must know this misnomer for billing purposes. Other names include infundibular cysts, keratinous cysts, and epidermoid cysts. Generally, these present as a compressible but nonfluctuant nodule, which can be diagnosed clinically due to a comedo-like central punctum that can be distinguished at the apex (Figure 12-1). Because the keratin material inside the cyst wall is highly inflammatory, any cyst that has ruptured can spark a vigorous inflammatory response that can be mistaken for cellulitis (Figure 12-2). Even if these do become superinfected, the treatment of choice is incision and drainage to remove the inflammatory and/or infected contents.

FIGURE 12-1 An epidermal inclusion cyst with a central punctum that looks like an open comedone.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-2 Local inflammation around an epidermal inclusion cyst can mimic cellulitis or an abscess. The best treatment is incision and drainage.

(Copyright Richard P. Usatine, MD.)

Pilar cysts (also known as trichilemmal cysts and commonly called wens) are very similar to epidermal inclusion cysts with the exception that the capsule is much thicker and the location generally on the scalp (Figures 12-3 and 12-4). Pilar cysts rarely have a punctum but the thickness of the capsule makes removal somewhat easier. These can also become very large but in most cases they are 5 to 20 mm in size. It is not unusual for the hair to become thinned or actually stop growing over the cyst (Figures 12-3 and 12-4).

FIGURE 12-3 A typical presentation of a pilar cyst (trichilemmal cyst or wen) on the scalp.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-4 A fairly large pilar cyst with hair loss over the cyst. A simple ellipse over the cyst will remove redundant tissue.

(Copyright Richard P. Usatine, MD.)

One variant of the epidermal cyst is the milium cyst. Milia are histologically identical to classic epidermal cysts but only grow to 1 to 2 mm. They are generally located around the eyes and central portion of the face (See Figure 33-20 in Chapter 33, Procedures to Treat Benign Conditions).

Cysts can be located almost anywhere but are common on the trunk, neck, face, and behind the ears. They range in size from millimeters to centimeters. Epidermal inclusion cysts are benign; however, there are rare proliferating epidermal inclusion cysts that can become carcinogenic. Any cyst that does not look 100% typical on excision should be sent to the pathologist. A full differential diagnosis is given in Box 12-1.

FIGURE 12-5 A Bartholin’s duct cyst.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-6 A branchial cleft cyst after removal.

(Courtesy of Frank Miller, MD.)

FIGURE 12-7 A solid cystic hidradenoma.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-8 Hydrocystoma around the eye. It is benign and has a very thin wall that is easy to cut.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-9 A mucinous cystadenoma near the eye.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-11 Pilonidal cyst.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-12 A thyroglossal duct cyst in a young girl. Note how it is midline. These will move up with swallowing.

(Courtesy of Frank Miller, MD.)

Dermoid cysts are far less common. They occur along congenital lines of cleavage (lingually, lateral eyes, behind the ears, and base of the nose) due to sequestration of embryonic cells. Unlike the common cyst, they are usually found in children and teenagers. So, young age is a warning sign for “something different.” Facial cysts in young children need to be approached with caution and may need an imaging study before performing an excision.

The occurrence of multiple true sebaceous cysts at a younger age is termed steatocystoma multiplex, which is a genetically inherited problem. These capsules are extremely thin. Small fluid-filled very thin-walled cysts around the eyes are called hidrocystomas (Figure 12-10).

FIGURE 12-10 Digital mucous (myxoid) cyst on the finger. They are most commonly found distal to the DIP joint.

(Copyright Richard P. Usatine, MD.)

Several techniques for removing epidermal inclusion cysts and pilar cysts are described below. The best approach depends on size, location, and cyst condition. The minimal excision technique is simplest. Other methods include elliptical excision and incision and drainage with iodine crystals. Each offers advantages in select cases. Familiarity with various techniques balances preventing recurrence with maximizing efficiency and cosmetic outcome.

Contraindications for Cyst Removal

• Avoid trying to remove cysts that are actively inflamed (Figure 12-2). Although it can be done successfully, wound healing may be impaired. The keratinaceous material in epidermal inclusion cysts is highly immunogenic and an inflamed cyst should be treated with incision and drainage and allowed to heal before attempting to remove the cyst wall. Antibiotics are rarely helpful. Small lesions can be excised going around the entire area of inflammation.¹

• Make note of the surrounding anatomy and the size/depth of tissue that contains the cyst. Consider deferring or referring lesions that overlie areas such as large vascular networks, special sensory organs, or cosmetically sensitive areas. With experience, these areas may be managed in the office, but this depends on comfort, experience, and support services. Be aware of the spinal accessory nerve when neck lesions are involved because the nerve lies immediately under the skin and can be easily severed, leading to difficulty in abducting the arm (See Figure 11-4 in Chapter 11). Also be careful to not cut the temporal branch of the facial nerve with cysts over the temple (See Figures 11-2 and 11-3 in Chapter 11).

• Diagnosis is usually made on clinical grounds before proceeding with removal. Keep the differential in mind even though the diagnosis may seem certain (Box 12-1). For example, a dermoid cyst on the face can communicate with the cerebrospinal fluid in some circumstances. Consider imaging for a possible dermoid cyst if the cyst has been present on the face since early childhood and is midline (Figure 12-13). When encountering something atypical, send samples to pathology, or confer with a colleague before proceeding.

FIGURE 12-13 A midline dermoid cyst on the face of a young girl.

(Copyright Richard P. Usatine, MD.)

Minimal Excision Technique

The minimal incision technique for removing cysts involves purposefully incising the cyst wall and expressing its contents allowing cyst removal through a smaller incision (linear opening or small punch rather than a larger ellipse that surrounds the cyst).

Minimal Excision Technique: Steps and Principles

Preoperative Measures

• After determining that the minimal excision technique is the best method for the patient, obtain informed consent. (See Appendix A for an informed consent form titled Disclosure and Consent: Medical and Surgical Procedures.)

• Determine the apex of the lesion. This is sometimes around a punctum (Figure 12-1).

• Prep the area with an antiseptic such as chlorhexidine or alcohol. Mark the apex with a line (Figure 12-14), a small ellipse, or a small circle to orient a punch depending on which technique is chosen to enter the cyst wall. It is also worthwhile to draw a circle around the widest margins of the cyst (Figure 12-14). You may use a fenestrated drape if you plan to place a suture.

• Inject anesthetic around the cyst with a 27- to 30-gauge needle. Avoid injecting anesthesia directly into the cyst because it may squirt cyst contents out of the punctum, producing an unpleasant smell (Figure 12-14). If the anesthesia enters the cyst and does not squirt out it may cause increased pain for the patient as the pressure builds inside the cyst. It is best to plan to inject around the cyst performing a ring block. In Figure 12-14 the arrows show how you can start at one corner of a square and inject at the arrow ahead each time so that the new injection will be less painful from the effect of the preceding injection. A fifth injection may be added to the skin above the cyst at the site for the planned incision to ensure a painless surgery (Figure 12-15). In Figure 12-16 the pressure of the anesthesia has caused some keratin to be extruded from the punctum without any harm.

FIGURE 12-14 Epidermal cyst on the face is outlined before injecting anesthesia. The solid line is drawn to match skin lines and to be about 40% of the diameter of the cyst. A ring block is marked with four arrows and each injection starts at the end of the previous arrow.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-15 The ring block has been performed without injecting into the cyst. The final injection is given over the cyst to make sure that the incision line is fully anesthetized.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-16 An otherwise invisible punctum is discovered when lidocaine creates pressure inside the cyst extruding keratin from the punctum.

(Copyright Richard P. Usatine, MD.)

Performing the Procedure

• Stretch the skin to anchor the lesion. Incise a linear or punch opening (Figure 12-17A and B) over the cyst apex and into the cyst itself. Alternatively, cut a small ellipse instead of a linear or circular opening.

• Express all cyst contents with firm digital pressure on the cyst and surrounding tissue (Figure 12-17C). Keep plenty of 4 × 4 gauze on the field to mop up the contents of the cyst.

• Identify the cyst wall and dissect it from surrounding tissues using blunt dissection with an iris scissor or curved hemostat. Curved iris scissors or any curved tissue scissors work very well. Once a small area has been dissected, you may grasp the cyst wall with forceps or hemostat (Figure 12-17D). Continue blunt dissection until the cyst wall is able to be pulled through your incision.

• Sometimes the skin incision needs to be extended or deepened to extract the entire cyst contents.

• If the cyst is attached to the fascia below, just snip this fibrous tissue with a scissor (Figure 12-18).

• Inspect the material removed. You should have extracted a nearly complete cyst wall (Figures 12-19 and 12-20). Pilar cysts have a thicker wall and are easier to extract intact than an epidermal cyst (Figure 12-21). You may be able to piece sections together like a jigsaw puzzle to make sure that the entire cyst is out.

• Inspect the cavity and be sure all of the (white) cyst wall has been removed.

• Sterile cotton-tipped applicators are useful for probing the cavity and cleaning out remaining cyst contents.

• Consider irrigating the cavity and surrounding skin with sterile saline or water especially if any cyst contents spilled into the incision.

• Repair the defect. With the minimal excision technique, often no closure is needed. If desired, the skin may be approximated with 4-0 to 6-0 nylon or polypropylene. Skin tapes may also be used. If a large cyst was removed through an elliptical excision, consider placing a deep layer of buried absorbable sutures to close the dead space. Some clinicians choose to not close small pilar cyst excisions and get good results. Sutures have the advantage of providing hemostasis and approximating the epidermis.²

FIGURE 12-17 (A) A 4-mm punch creates an opening into the underlying epidermal inclusion cyst. (B) The punch is removed and the keratinaceous material is seen inside the punch and in the cyst. (C) The cyst contents are expressed with pressure from both sides. (D) The cyst wall is shiny and seen being pulled through the punch incision.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-18 A small emptied cyst is pulled through a small punch opening and freed from underlying tissue using an iris scissor.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-19 Pulling a large emptied cyst wall through the opening created by an ellipse in the abdominal wall.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-20 A relatively intact epidermal cyst near the shoulder is extracted through a linear incision. Many epidermal cysts are not so well encapsulated.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-21 Pilar cyst has a thick wall and keeps its spherical anatomy in most cases even if it was cut and emptied.

(Copyright Richard P. Usatine, MD.)

Alternatives to the Minimal Excision Technique

A couple of alternatives to the minimal excision technique are worth discussing.

Elliptical Excision

Full elliptical excisions are covered in Chapter 11. This technique may be a good option if cysts have been heavily manipulated or have recurred. One approach is to avoid cutting into the cyst wall and attempting to remove the cyst whole. Another approach is similar to the minimal cyst removal in which the cyst is cut on purpose and the contents are evacuated to allow the cyst to be removed through a smaller ellipse. If the cyst is large and elevated, make sure the width of the ellipse is equal to the width of the cyst to avoid dog ears (standing cones).³ This is especially true with large protuberant pilar cysts (Figure 12-22). The scalp will not lay flat unless the ellipse is as long as the cyst. The elliptical excision method is preferred with any large protuberant cysts that would leave redundant skin if the cyst is excised through a punch or a linear incision.

FIGURE 12-22 This large pilar cyst will be removed through an ellipse that extends across the full diameter of the cyst. This will allow the scalp to lay flat once the cyst is removed. If the ellipse is made shorter, then standing cones will result on both sides of the repaired defect. Note that the hairs were clipped with a scissor rather than shaving the scalp. Shaving increases risk of infection, but snipping with a scissor makes the surgery easier with no increased infection risks.

(Copyright Richard P. Usatine, MD.)

Incision and Drainage Plus Iodine Crystals

One alternative consists of a combination incision and drainage (I&D) of the cyst followed by placing two iodine crystals in the center of the cyst. Over a period of several days, the cyst will harden and darken. This may then be expressed through the skin on the return visit. This is a fairly simple technique with similar cosmetic results to the minimal excision technique. It does however, require a follow-up visit and some patience as the cyst darkens and hardens. Iodine crystals USP are available from the pharmacy. The size used is dependent on the size of the cyst. It works well for cysts up to about 2 cm.²

Lipomas

Lipomas are subcutaneous benign tumors composed of adipose tissue held together with connective tissue. Although they may be encapsulated, in general they are more amorphous, lobulated masses that are either slightly lighter or darker than surrounding adipose. Often it is nearly indistinguishable from normal tissue by color, but the fat may be held together so that it is separate from the surrounding subcutaneous fat. Lesions typically arise after the fourth decade of life and present as single or multilobed soft tumors that are easily compressible and have a doughy consistency. Lipomas most commonly arise over the neck and trunk, though they can also be found on the extremities and face. Usually patients complain of lipomas when they are located on pressure-bearing areas and become painful, when they arise in cosmetically sensitive areas, or when they become very large. In these cases, and in instances of rapid growth, it is reasonable to remove them. Another indication would be if the diagnosis is in doubt.

Lipomas can usually be diagnosed clinically, although the differential diagnosis includes many of the same entities discussed for cysts (Box 12-1). Additional considerations are hematoma, panniculitis, rheumatic nodules, and metastatic cancer. Rapidly growing subcutaneous masses should be removed and sent for pathology. Several approaches are used to remove lipomas: incision and expression, elliptical excision, and liposuction.

General Considerations

Liposarcomas can appear similar to lipomas, but do not arise from lipomas. In the case of some worrisome lesions, first consider needle aspiration or imaging.4,⁵ However, a full excision will always give the best sampling of the lesion to the pathologist.

Anatomic considerations are important as well. Lesions that present in the sacroiliac region can occasionally communicate with the spinal column. Here, consider consulting with neurosurgery or ruling out nerve involvement by obtaining an MRI. Also of note, lipomas on the forehead can track behind the fascial plane and under the frontalis muscle. Forehead lipomas are frequently removed in the office but contrary to most other lipomas, are not as discrete and thus are more difficult to remove (Figure 12-23). On exam they will generally feel larger than they actually are, causing the surgeon to question if the lesion was really removed. Despite these caveats, lipoma excisions are generally straightforward.

FIGURE 12-23 (A) Lipoma on the temple/forehead is marked with a dotted line around the circumference and a solid line to guide the incision along skin lines. (B) Lipoma removed without damage to the temporal branch of the facial nerve. (C) Linear incision closed with running sutures.

(Copyright Richard P. Usatine, MD.)

Incision and Pressure Method

The easiest method to remove lipomas is the incision and pressure method. Draw out the linear incision so that it is approximately one-third to one-half the diameter of the lipoma (Figure 12-24A). Make a linear incision through the skin over the top of the lipoma. Hold the No. 11 blade perpendicular to the skin and cut through the skin into the lipoma with a sawing motion. Fortunately, lipomas are relatively avascular so little bleeding should be encountered. If there is much bleeding, reassess the diagnosis and procedure immediately.

FIGURE 12-24 (A) Lipoma on the forearm marked for linear incision and removal. (B) The lipoma is extruded from the incision with the pressure from four fingers. (C) Firm pressure around and below the lipoma delivers it through the small opening with one hand.

(Copyright Richard P. Usatine, MD.)

Once the incision has been made, insert and spread the curved hemostats around the edge of the lipoma to break up the fibrous bands that attach it to the surrounding tissue. Do this through 360 degrees and try to get under the lipoma as well. Then express the lipoma through the incision using digital pressure (Figure 12-24B). If this does not work, use the hemostat again to free the lipoma further. If this still does not work, consider extending the incision on both sides to give more room for the lipoma to come out. Pulling the lipoma with the hemostat clamped on it can help while an assistant is squeezing the lipoma out from below with digital pressure.

Once the lipoma is out, see if it appears whole and explore the cavity to make sure the entire lipoma has been removed. Bleeding should be nonexistent to minimal. Hold pressure on the defect to express any blood or fluid. The incision can be closed with simple interrupted sutures or subcuticular sutures. If the defect is large consider placing some deep sutures to close dead space (see Chapter 6, Suturing Techniques). Some clinicians use Steri-Strips with no sutures underneath a pressure dressing. With experience and efficient office staff, this procedure can be done in 10 minutes. Even a large lipoma can be removed using this method (Figure 12-25).

FIGURE 12-25 (A) Large lipoma overlying the left latissimus dorsi muscle of a young man. (B) Use a curved hemostat to separate the lipoma from surrounding tissues. (C) Cut the lipoma from its attachments below. (D) Final release of the lipoma shows that it was lying directly on the chest wall muscles. (E) Large partially encapsulated lipoma in the hand for examination.

(Copyright Richard P. Usatine, MD.)

Examination and Pathology

Inspect the lipoma and feel it between your fingers. It should be a contiguous yellow mass without significant vascularity or calcifications (Figure 12-25E). Any hint of abnormality or odd behavior of the tissue during the procedure should prompt you to send the specimen for pathology. Any lesions with significant vascularity, size, calcifications, or other worrisome features should be sent to pathology to confirm a benign diagnosis.

Punch (Enucleation) Technique

The punch technique can be used to remove lipomas. Enucleation involves entering the lipoma through a small punch through the dermis and scooping out, or enucleating, the lipoma with a small curette.

Removing the Lipoma

• Center the punch tool over the lipoma, stretching the skin perpendicular to the skin lines. With a twisting motion, punch through the dermis and into the lipoma.

• Insert the curette through the incision and using a finger as a guide and boundary on the surface, begin to free the lipoma by scraping it from the surrounding tissue.

• Bring a section of the lipoma through the opening and grasp it with a hemostat. Continue to curette until the entire lesion is delivered out of the small opening (Figure 12-26). Firm digital pressure around the lipoma will aid in the extraction.

• For larger lipomas some advocate multiple small incisions or punches to perform segmental extraction.⁶

• A 6-mm punch may be used for larger lipomas.

• For small lipomas a punch biopsy may be used as the opening and the lipoma can be extracted manually without a curette similar to the method described for the linear incision technique.

FIGURE 12-26 Small lipoma being extracted through a 6-mm punch incision.

(Copyright Richard P. Usatine, MD.)

Elliptical Excision of A Lipoma

A true elliptical excision for removal can be practical for larger lipomas or those under thick skin (back of the neck, posterior trunk) and with lesions that are of uncertain diagnosis or unusually firm. The elliptical excision is covered fully in Chapter 11. It may be more helpful to leave the elliptical piece of skin attached to the dermis and use the skin as a convenient handle to manipulate the lipoma with a hemostat, clamp, or forceps. The scar will be larger using this technique, but in some instances that is not a concern.

Complications of Lipoma Removal

Complications to lipoma removal include scarring, formation of hematomas or seromas, infection, and recurrence. The linear incision and enucleation methods should minimize any scarring by virtue of limiting the size of the incision and having an incision that is not under pressure after the lipoma is removed. Seromas and hematomas are rare but can be treated with aspiration or expression. These are better addressed before they form by applying a pressure dressing after the surgery is completed.

Digital Mucous (Myxoid) Cysts

Digital mucous cysts or myxoid cysts are similar to ganglia but arise on the distal fingers and occasionally toes (Figures 12-27 and 12-28). These are the most common cysts on the hand and are benign. The exact etiology is uncertain, but the cysts likely form from the mucoid degeneration associated with arthritis. Cysts usually present after the fifth decade of life, but can present earlier when associated with arthropathy such as rheumatoid arthritis. The most common location is the distal interphalangeal joint, on the dorsal aspect. Lesions that occur in the proximal nail fold can distort the lunula, put pressure on the matrix, and cause nail deformities and pain (Figure 12-28).

FIGURE 12-27 Digital mucous cyst on a toe.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-28 Digital mucous cyst causing nail deformity. The pressure of the cyst on the matrix typically causes a depressed trough.

(Copyright Richard P. Usatine, MD.)

When treatment is sought, options range from observation to joint surgery with osteophyte removal and flap reconstruction. In the office setting, the most common options are draining with repeat sterile needling and cryotherapy.^1,2 Alternatives include the injection of sclerosing agents, steroid injections, or excision with flap repair. All options risk recurrence with radical joint surgery as the most definitive and most costly option.

Needling and Cryotherapy

• Obtain informed consent and discuss the small risk of scarring, nail deformities, infection in the joint space, and recurrence (10% to 15% with cryotherapy).⁷

• Offer to provide local anesthesia with lidocaine. This can be done with 1% to 2% lidocaine without epinephrine with a 30-gauge needle at the site of the cyst.

• Prep the area with an alcohol swab.

• Puncture the lesion with multiple needlesticks and drain out the thick clear to serous fluid inside (Figure 12-29).

• Using a cryosurgery probe or spray nozzle, create an ice ball with a diameter 2 to 3 mm beyond the extent of the cyst (Figure 12-30). Let this thaw and repeat.

FIGURE 12-29 (A) Needling a digital mucous cyst. (B) The gelatinous material is similar to synovial fluid. (C) Collapsed digital mucous cyst.

(Copyright Richard P. Usatine, MD.)

FIGURE 12-30 Cryotherapy of a digital mucous cyst after it was punctured with a needle and drained. Aim for a 2-mm margin of freeze around the lesion.

(Copyright Richard P. Usatine, MD.)

Coding and Billing Pearls

Epidermal cysts (ICD-9 code 706.2) are skin lesions and as such, excisions are coded by the size of the cyst, the location, and the fact that they are benign. Simple excision and repair includes the anesthetic, the excision, the repair, and suture removal. The size is based on the size of the cyst, not the size of the incision so a minimal cyst removal is not compensated at a lower rate because the incision was shorter. Additional charges are made for an intermediate closure if deep sutures are needed to close dead space or approximate wound edges under tension. The intermediate closure charge is based on the size of the final closed wound. Make sure to document the reason for the intermediate closure to avoid a denial of the service.

If the cyst was infected or inflamed and the procedure performed was only an incision and drainage, use the code for simple I&D (10060). Use this code if the lesion was opened and drained but not packed or sutured. If multiple cysts were done, if it was complicated with the use of packing or iodine crystals, or if the sack was removed, then the correct code is 10061 for “multiple or complex removal.” Note that just adding packing to the opened incision and drainage automatically qualifies the procedure as a complex I&D (10061).

Lipoma excisions may be coded as for a skin lesion or a subcutaneous tumor. If the lipoma is superficial in the subcutaneous fat below the skin, the removal may be coded the same as for an excision of an epidermal cyst (excision of a benign skin lesion). Similar to epidermal cysts, the size is based on the measurement of the lipoma and not the incision. Also, if a two-layered closure is performed, document the necessity for this and bill for an intermediate closure.

Lipomas may also be coded with the new 2010 CPT codes for excision of a subcutaneous tumor based on anatomic location. Some coders advocate using these codes only for deep lipomas including those under fascia or under muscle. Other coders state that all lipomas should be coded with these codes. See Table 38-13 in Chapter 38, Surviving Financially, for the specific soft tissue tumor codes based on location of the lipoma. The most commonly needed codes for lipomas are listed in Table 12-1. These soft tissue tumor codes are all inclusive. Neither the length of the incision nor the type of repair that is used matter. The large lipoma in Figure 12-25 was deep based on the visibility of the latissimus dorsi muscle at the time of excision and could easily be coded as 21931. If a decision is made to code it as a skin lesion (an acceptable alternative), then the code used would be 11446 for a benign skin lesion excised with a diameter over 4.0 cm. Both coding methods pay well and are considered legitimate for the procedure performed. The specific ICD-9 codes for lipomas are 214.0 for the face and 214.1 for other areas.

TABLE 12-1 Subcutaneous Soft Tissue Tumor Excisions (Including Lipomas)

As of 2010, four new codes (21011, 21012, 21013, and 21014) are available for reporting the excisions of soft tissue tumors (including lipomas) of the face and scalp. If a lipoma is less than 2 cm in maximum dimension, report code 21011. If the lipoma is larger than 2 cm, report 21012. If the tumor is subfascial (i.e., intramuscular or subgaleal) and is less than 2 cm in maximum dimension, report code 21013. If it is larger than 2 cm, report 21014. Therefore, the excision of a 3-cm submuscular lipoma of the forehead is reported with code 21014.

Speak with staff and/or consultants who support coding and billing functions to help make decisions when the best coding strategy for a specific lipoma is not clear.

(For further tips see Chapter 38, Surviving Financially.)

Conclusion

The most common “lumps and bumps” that present in an outpatient setting can be managed effectively with a combination of the techniques described in this chapter. New techniques minimize scarring and are convenient for patients and providers. Learning these few tricks should expand your capabilities and improve your efficiency and effectiveness in treating these common problems.