Dermatology Coding Alert

Question: My dermatologist removed a malignant mole last week, which I reported with 11600. The patient is returning for the same area to be excised larger. Is there another code, or will I use 11600 again?

California Subscriber

Answer: You should code a malignant lesion according to the size and margin noted in the medical record. If the dimensions fit, you should use 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less) again, assuming that the reason the re-excision is being performed is because the margins were not clear and not because of some issue related to the scar or repair.

Mind your modifiers: If the dermatologist performs the second procedure in the global period of the first, you’ll need to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the second procedure. You should append modifier 58 when a procedure or service is planned or anticipated at the time of the original procedure (staged), is more extensive than the original procedure (which is the case in this scenario), or represents therapy following a surgical procedure.

Tip: You need not return the patient to the operating room to report modifier 58. Also, be sure to use the same malignant diagnosis again even if the most recent excision shows no cancer cells in the specimen (which is common in these re-excision situations).