General Surgery Coding Alert

The other three categories are used when the pathology report does not indicate an active malignancy. The absence of cancer is the only characteristic shared by neoplasms in these categories, and even that is questionable in many cases. Nonmalignant neoplasms are categorized as follows:

Benign. Benign neoplasms are cancer-free. For example, a fibroadenoma of the breast, which does not spread and does not return once it is removed, should be coded as a benign neoplasm (217). A benign mass has far fewer ramifications for the patient, which only increases the importance of waiting for the pathology report. If the surgeon uses a malignant diagnosis before the pathology report returns, the codes used for the procedure may be incorrect. Worse still, the patient may be erroneously labeled as having cancer, with all the ensuing detrimental effects to her ability to purchase health insurance.

Uncertain Behavior. If the pathology report returns with indications of atypia or dysplasia, the neoplasm is considered in transition from benign to malignant. If the process continues and the mass is left untreated or is not removed, a neoplasm that is not initially diagnosed as malignant will eventually become so. For example, benign adenomatous polyps are at high risk for becoming malignant if they remain undiagnosed and untreated. This category is often confused with the "Unspecified" category.

Unspecified. This category should be used only when the surgeon cannot determine the nature of the neoplasm. If the surgeon excises a lipoma but does not wait for the pathology report, for example, these are the only codes that should be used, Mueller says. "The surgeon may have decided, based on experience and the location and nature of the lump, that it is benign and that a pathology report isnt necessary. But because the lump wasnt sent to pathology, there will be an impact on payment," she says.

Procedures associated with unspecified neoplasm diagnosis codes are typically not payable, she says. "Take an excision. Carriers expect the surgeon to know what he or she removed and may not pay when the unspecified neoplasm codes are the reason for the excision," Mueller notes. "The unspecified mass qualifies for an E/M visit, but not necessarily for a biopsy, much less an excision. For a biopsy to be covered, there has to be discomfort, or the mass has to change in size or shape." A surgeon who does not wait for the pathology report runs the risk of performing the biopsy for free, Mueller adds.

Sometimes the surgeon removes a mass (such as a lipoma or a skin lesion) that returns benign from the path lab. Carriers may not pay for the excision, so patients should be asked to sign an advance beneficiary notice (ABN) to indicate they are aware they may have to pay for the removal of the mass themselves.

If the mass is removed at the request of the patient (because it is unsightly, for example) and there is no chief complaint, the patient should be asked to pay up front for the procedure and sign an ABN.

Note: Neoplasms that occur on or near the skin of an anatomic site should be assigned diagnosis codes for skin, not the body area in question. For example, if the surgeon removes a lesion from the skin of a womans breast that pathology determines is benign, the correct code is 782.8 (Changes in skin texture).