Subcutaneous vs Subfascial

Question:

If the provider says in their documentation that they went into the subcutaneous tissue and to the fascia to excise a 4 cm lipoma from the back, is this subfascial? This always trips me up when coding!  

Answer:
In the scenario above, this is only to the fascia, not through or below the fascia. The lipoma excision is only within the subcutaneous tissue.

Based on the scenario presented, the appropriate CPT code is 21931.  

*This response is based on the best information available as of 12/5/24.