# Basic Excision question



## bmapc2

Hi-
I am new to coding and have a basic question about coding an excision. If a neoplasm of uncertain behavior is removed from pt's mid back and the pathology report comes back as "Compound nevus with mild cytologic and
architectural atypia; lateral (peripheral)
margins involved."
My question.....do I use CPT codes for benign or malignant excisions? and if the pt has to come back to excise more from the same region, is this considered part of the original procedure?  Hope this makes sense....
any help is greatly appreciated!

Nancy T.


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## ERINM

The codes used would be benign for sure. What was the first surgical procedure done to determine pathology, Biopsy, excision, etc.? This will determine what you can charge for the removal of margins.


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## LCRUZ515

The excision codes would be benign and the dx would be 238.2 for an atypia dx.


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## mitchellde

bmapc2 said:


> Hi-
> I am new to coding and have a basic question about coding an excision. If a neoplasm of uncertain behavior is removed from pt's mid back and the pathology report comes back as "Compound nevus with mild cytologic and
> architectural atypia; lateral (peripheral)
> margins involved."
> My question.....do I use CPT codes for benign or malignant excisions? and if the pt has to come back to excise more from the same region, is this considered part of the original procedure?  Hope this makes sense....
> any help is greatly appreciated!
> 
> Nancy T.



Be careful about calling this an uncertain behavior neoplasm prior to excision.  It is not, it is a skin abnormality so use a 709.x code.  I agree the path is giving you uncertain behavior so it is now a 238.x code.  The rule on which excision code to use for uncertain pathology, is if the margins were narrow then code it benign, if the margins were wide then code it with malignant excision codes.  If there needs to be a re-excision you will code the same flavor of excision as you did for the original and you may need a modifier if it is still in the global.


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## preserene

If you place a code in this series of 709x , well it may be into the 709.09.
But as per my openion, as she said code 238. is not agreeable at this stage.
even the 709 i would not opt for, becuase it is for 'dyschromia' which usually includes the hyper and hypopigmentations of the skin. the code 709 itself suggests the exclusion of pigmented nevae because it is the melonocytic neoplasmic pigmentation of the skin- pigmented nevae, an dwe do have a distinct code for benign neoplastic skin nevae in ICD-9 CM.
So I go for the *216x series*, 4th digit being classified according to the site- even at the initial diagnosis because the compound nevae are in the same group of pigmented nevae 
Once the path. report has come and the surgeon is pertinent to document it for benign it is left to him because he goes as per sites, AAD rules and clinical  and histopath norms;it is his right to do so. It is right and justifiable as per the available Path report as compound nevae.
So long as our CPT manual has not classified the variants of these atypia, dysplasia or hyperplasia of pigmented nevae , and so long as there is always dispute of /or uncertainity of pin pointing thier place in the functional certainity of "atypia" nomenclature, as to which goes where of the neoplastic classification, and so long as it is unclear if future molecular diagnostics will help or obfuscate the answers, until then we go with our M code which says it belongs to, 
*M8760'0'.* and place them in benign just for coding purpose only- as the part of our work.
Thank you


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## preserene

CUTANEOUS MELANOMAS AND MDN: 
Just an overview to capture some knowledge about the MDN and its atypia:
Early detection of melanoma carries an excellent prognosis, with surgical excision often beingcurative.
Factors leading to early diagnosis and effective treatment are critical.
Clinical history is essential for accurate diagnosis. Acronym ABCDE – asymmetry, border irregularity, color variegation (2% to 8% of melanomas are reportedly
amelanotic), diameter over 6 mm, evolution or changes in
a previous nevus. Other important information includes
site and duration of lesion, history of prior biopsy/trauma
(such as excoriation) at that site, recent sunburn/sun
exposure, personal history  of previous melanoma, family
history of melanoma, and age of the patient. The age of
the patient is of particular importance.
 Cytological atypia and pagetoid spread frequently seen in
dysplastic nevi may be features of several other benign
melanocytic lesions, such as genital type nevi, acral nevi,
neonatal or childhood nevi and recurrent or traumatized
nevi.
Whenever possible, complete or large excision
should be made to permit histological assessment
of the entire lesion.

The proper method of biopsy and definitive surgical excision
of cutaneous melanoma is vital for optimal patient outcome.
. Superficial shave biopsies frequently preclude
the accurate assessment of Clark's level and tumor thickness
of melanomas. This uncertainty may result in a
recommendation for complete excision after an initial small
biopsy so that the residual lesion can be studied.
Any biopsy performed detect the histologic features that give rise to clinical atypia is always better for the better prognosis.
According to the American Academy of Dermatology (AAD)
guidelines2, whenever possible, the atypical lesion should
be excised with narrow margins for diagnostic purposes.
The following considerations are recommended for biopsy:
1. A narrow margin, excisional (bda) biopsy is considered
the procedure of choice for adequate histologic
examination.
2. An incisional biopsy technique is appropriate when the
suspicion for melanoma is low, when the lesion is
large, or it is impractical to perform a complete
excision. In such cases, multiple biopsies of different
regions are warranted, because a solitary biopsy may
not represent the worst area of the lesion in up to
40% of cases.
3. A repeat biopsy should be performed if the initial
biopsy specimen is inadequate for accurate histological
diagnosis or staging.
4. Fine needle aspiration cytology should not be used to
assess primar y cutaneous and mucosal tumors.


Dysplastic Nevus should be considered a potential
precursor lesion to melanoma and requires careful
surveillance and prompt treatment.
About one-third of melanomas arise from preexisting nevi
(both acquired and congenital types), whereas the
remainder appear to arise de novo. The melanocytic
dysplastic nevus (MDN) remains a controversial issue, and
contrar y views about its existence are reported in the
literature. Part of the problem with these lesions is the
lack of a precise definition. The consensus statement issued
by the National Institutes of Health in 1992 required the
presence of architectural disorder only (and not cytological
atypia) to establish a diagnosis of dysplastic nevus3. To date,
however, most dermatopathologists believe that both
architectural and cytological atypia must also be present.
The cytological atypia in a dysplastic nevus is generally
random and patchy, with atypical cells punctuating a
background of cells with minimal or no atypia.
Several groups have demonstrated epidemiological,
morphological, immunohistochemical and molecular
differences banal nevi, dysplastic nevi and
melanoma, supporting the view that dysplastic nevi occupy
an intermediate position in the hierarchy of melanocytic
lesions and may be precursors of cutaneous malignant
melanoma4,5. The clinical relevance of MDN lies in its
association with an increased risk of cutaneous malignant
melanoma.
According to the AAD guidelines, atypical
lesions should be excised with narrow margins of about
2-3 mm for diagnostic purposes, whenever possible.

Most often, clinicians do not include treatment recommendations for mildly atypical dysplastic nevi that appear to have been completely
excised or are focally present at the margins.They  suggest
conservative re-excision of dysplastic nevi with moderate
atypia that extend to a margin. If the margin is substantially
involved, advising a complete excision is essential. They adhere to
the standard recommendation of 5 mm margins in all
severely atypical nevi that involve the margin. they include
in their reports a measurement to the closest biopsy margin
in severely atypical nevi.
These are the general outlines for the MDN we come across.


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## wegrant630

We always wait to bill the charge until the pathology comes back.  If you bill it as a benign lesion, and the pathology is malignant, you have left money on the table.  Usually the pathology only takes a couple of days to send back their report, so it would worth your while to wait.


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## preserene

Thank you very much for your kind response. Well I totally agree with you: we wait and give the coding after the final excision report. 
I had been all along dealing with the present available pathological documented scenerio for coding as bmpac2 stated, "the pathology report came back as "Compound nevus with mild cytologic and architectural atypia; lateral (peripheral)
margins involved."
I just gave the information to get know a bit more what these terms all about.
 Thank you very much


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## DONNA GRIMM

I have a question about "repeat biopsies". If a patient had a biopsy but made the decision not to have treatment, what is the allowable timeframe for a repeat biopsy of that lesion that had previously been diagnosed as skin cancer? For some reason I thought that one of the guidelines was that a repeat biopsy could be done after 6 months.


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