# Excision of lesion CPT coding



## CCMongillo

When choosing a cpt code for lesion removal do you wait for the pathology report to code benign or malignant lesion removal or do you code by what the MD is stating on his procedure note which may only be mass or lesion not stated as benign or malignant? Any input with reference is appreciated.


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## M.Slade

I was always advised that it is best to code off the pathology report for highest specificity and accuracy on lesions, since there aren't such a thing as "Not specified" lesion codes.


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## juliabiz@hotmail.com

I was taught in my medical coding class earlier this year, that you always assume a lesion is benign, unless the pathology report states specifically that it is malignant. My coding teacher runs her own billing and coding service, is certified.


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## DeeCPC

"... you always assume a lesion is benign, unless the pathology report states specifically that it is malignant."

We never assume anything in coding...so we want a path report.


Dee
CPC, CPMA, CPCD


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## mitchellde

juliabiz@hotmail.com said:


> I was taught in my medical coding class earlier this year, that you always assume a lesion is benign, unless the pathology report states specifically that it is malignant. My coding teacher runs her own billing and coding service, is certified.



I hate tto contradict your instructor but she is incorrect on this.  First you cannot assume anything, second you cannot code what is not documented.  The provider documents that an anomly is removed so you cannot code benign, in additon thisis the patient's diagnosis so we must code for the patient.  Since the pathologist is a doctor we can code from the path report which is the patient's diagnosis.  You must hold the claim for excision until the path is received.


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## CCMongillo

So what I am understanding is that if an MD states excision of mass or lesion on a procedure note and the path comes back as a cancer than a malignant lesion cpt is used or if op note states excision of mass or lesion and the path is a benign result a benign lesion cpt is used. It is confusiing to me if a cpt is choosen from the op note or from the definitive path result. Thanks for all of your input on this. Does anyone have a reference that they have confirmed this with?


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## mitchellde

CCMongillo said:


> So what I am understanding is that if an MD states excision of mass or lesion on a procedure note and the path comes back as a cancer than a malignant lesion cpt is used or if op note states excision of mass or lesion and the path is a benign result a benign lesion cpt is used. It is confusiing to me if a cpt is choosen from the op note or from the definitive path result. Thanks for all of your input on this. Does anyone have a reference that they have confirmed this with?



You are correct in what you state, that is for skin lesion excisions we wait for the path report. This is a decision the AMA made several years back and it is why you see excision codes in only benign or malignant choices, you are not allowed to guess and can only code known neoplasms.  Please check out my article from the August coding edge about coding the correct diagnosis.  Also if you look at the CPT assistants listed under the excisions in the CPT book one of them will have this information and it is an older one around the year 2000 or so.


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## Peter Davidyock

Most Physicians I know have the clinical acumen to define a benign lesion by site. If they suspect a malignancy (cancer caused lesion) they will perform a full thickness skin biopsy for path.
A benign lesion is an anomoly caused by something other than cancer. Look up the definition. It's really no more complicated than that. Physicians will send benign lesion samples to path as well for safety's sake but if they are only noting "Lesion" 98 percent of the time they are referencing benign.
I think the single biggest problem with coding these is the lack of understanding of what constitutes a benign condition.


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## mitchellde

I do not think they can define a benign lesion by site, they can suspect it because it has characteristics of benign but they have no way of knowing the cellular morphology.  The CDC defines the codes of benign, malignant, and uncertain behavior as morphologic diagnosis based on microscopic examination of the cells.  The physicians send the specimen for path to confirm a suspicion, and we cannot code suspicion.  We cannot code benign because the provider states "lesion"


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## CCMongillo

Thanks Debra for your reply....I will try and locate the documentation that you are reffering to. I have been struggling with a conflict for I feel that within my CPC and CPC-H training and certification I have learned that you identify a lesion based on the path to benign or malignant and then choose the excision cpt code. The hospital outpatient department that I work within is making a cpt code choice of  benign or malignant based solely on op note therefore sometimes coding malignant lesions to benign. They are basing their decision stating that you code cpt code at the time of procedure not path for this was not known at the time of excision. Hopefully I will be able to locate documentation to bring forward. Thanks again.... I appreciate the information and support of this forum.


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## Peter Davidyock

I double dog dare you to say that to your physicians Deb.


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## mitchellde

Also the difference in benign and malignant is not that one is cancer and the other is not.  they are in fact all neoplasms (cancer).  the difference in benign and malignant is that a benign neoplasm has cells that stay within the boundarys of the anomaly whereas with malignant the cells multiply and spread out (simple explanation), Again the physician on visual inspection cannot know what type of cell(s) are within the "lesion"


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## mitchellde

Oceanlivin said:


> I double dog dare you to say that to your physicians Deb.



I already have many times, and they agree with me every time!


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## Peter Davidyock

We are not discussing cancers Deb. We are discussing lesions.

Scar tissue is a benign lesion.
I am sure physicians can recognize a scar by sight.


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## mitchellde

no scar tissue is not a benign lesion, it is a scar, the AMA has instructed that if a scar is excised out we are to code it using benign excision codes.  we do not use a dx code for benign when coding a scar and it is usually described as keloid or just scar which has its own code and is not a benign neoplasm. so you may not use a 216.x code for a scar.


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## Peter Davidyock

By definition a scar is a lesion.
Lesion: any structural change in a body part as a result of injury or disease.
Scar: dense fibrous tissue that forms (that indicates structural change) over a healed wound.
A Ghon Focus is a scar signature on a lung x-ray of an adult left by tuberculosis in childhood.
A Ghon Focus "is" a lesion of the lung by definition and is readily identifiable by sight. In this case looking at the xray.
You are missing my point Deb.
CCMongillo everything you need to know to answer your question can be found in the definition of a benign lesion.


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## CCMongillo

My reasoning for posting to the forum is not the difference from benign or malignant dx of a lesion.....I leave this up to the MD and or Pathology. My question is as a coder placing a cpt do we choose from the opinion of the MD at the time of the excision or do we wait for the pathology with definitive tissue diagnosis of the lesion? Sometimes this can be different when the physician only states lesion or mass and the pathology of the lesion defines  pre cancerous cells or a definite cancer.


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## mitchellde

Oceanlivin said:


> By definition a scar is a lesion.
> Lesion: any structural change in a body part as a result of injury or disease.
> Scar: dense fibrous tissue that forms (that indicates structural change) over a healed wound.
> A Ghon Focus is a scar signature on a lung x-ray of an adult left by tuberculosis in childhood.
> A Ghon Focus "is" a lesion of the lung by definition and is readily identifiable by sight. In this case looking at the xray.
> You are missing my point Deb.
> CCMongillo everything you need to know to answer your question can be found in the definition of a benign lesion.


I am not missing the point but you are arguing from different issues at the same time.  I am speaking of skin lesions in particular in that the skin lesion may not be defined as benign or malignant without path and the excision may not be coded without path.  A scar of the skin is not a benign lesion either and as I stated it has its own code we cannot decide to use a benign lesion code.  As far as a lung scar going to benign neoplasm of the lung without benefit of path this too cannot be done.  Bottom line is if the provider does not document it we cannot code regardless.  You may not take an xray documented as lung scarring and code a benign lesion of the lung.     And Neoplasm is another term for cancer, when you want to code a lesion benign then you are coding it as a benign neoplasm which is cancer non malignant.  
A ghon focus is not coded as a benign neoplasm of the lung that is my point.  while scars are benign as to cells and morphology if you will they are not benign neoplasms.
CCMongillo- You cannot code a mass or lesion as either benign not malignant, in this case you can code the mass or wait for path, for a skin excision you are required to wait for the path.  so skin aside for any other surgery if you do not wait for the path then you may code the surgery and submit with the code of why the surgery was performed, meaning a mass or abnormality, you may not however make a quantum leap as to what the path may show and code either benign or malignant.


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## Peter Davidyock

It's all good Deb.
My point is (was in the beginning) that a lesion can certainly be coded as benign.
A benign skin lesion is "NOT" cancer.
I am sorry to keep returning to the same way to qualify what I say but:
Cancer: A "MALIGNANT" and invasive growth or tumor.

Something classified as benign is not a cancer just because it happens to say benign.
And in so much as misdirection goes I do not recall saying anything about coding Ghons'.
My example was used to establish the fact that physicians can most certainly identify lesions by site characteristics.


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## mitchellde

i sill disagree when you are coding benign lesion you are code a cancer that is by morphology benign which is determined by path. You cannot code a lesion as a benign neoplasm.


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## DeeCPC

I agree with Deb.  I have worked with a large dermatology group (20+ providers) for years.  These docs usually did a biopsy and then had the patient return when necessary.  There were times when the assessment stated wart, scar or skintag but path came back as actinic keratosis or cancer.  

So to answer the question at hand:
"My question is as a coder placing a cpt do we choose from the opinion of the MD at the time of the excision or do we wait for the pathology with definitive tissue diagnosis of the lesion? Sometimes this can be different when the physician only states lesion or mass and the pathology of the lesion defines pre cancerous cells or a definite cancer."

Everything I have ever read on the subject has stated that proper coding is to wait for pathology.  

Dee
CPC, CPCD, CPMA


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