General Surgery Coding Alert

Question: What is the proper coding if my surgeon takes a biopsy and sends it to pathology for a frozen section, the sample returns positive for malignancy, and the surgeon then takes a larger margin to excise the whole lesion? Can I report both the biopsy and excision?

What if pathology returns negative for malignancy and the surgeon subsequently takes a small margin to excise the entire lesion?

South Carolina Subscriber

Answer: CMS policy, as set forth in chapter 1 (-General Correct Coding Policies-) of the national Correct Coding Initiative, clearly states, -If the decision to perform a more comprehensive procedure is based on the biopsy result, the biopsy is diagnostic, and the biopsy service may be separately reported.-

In each case you cite, the biopsy establishes the lesion's character, which then determines how wide of an excision to perform. In other words, your surgeon bases his decision to perform wide or narrow excision, respectively, on the biopsy's results. Therefore, under Medicare rules, the biopsy is separate, and you may report both the biopsy and the excision.

To alert the payer that the biopsy and excision are distinct and separately reportable, you should append modifier 59 (Distinct procedural service) to the appropriate biopsy code.

But when the surgeon removes an entire lesion and then sends a portion to pathology, the -biopsy- is incidental and included in the excision, per CPT and CMS guidelines. CPT states, -The obtaining of tissue for pathology during the course of [excision] is a routine component of such procedures [and] - is not considered a separate biopsy procedure.- CCI instructions support this, specifying, -When a biopsy is performed as part of a lesion removal, it is part of the overall procedure and is not to be considered as a separate procedure.-

In effect, the surgeon was excising the entire lesion anyhow, so the biopsy wasn't -necessary- to establish the need for the excision. The biopsy, therefore, isn't separately reportable or payable.

However, if the surgeon must return the patient to the operating room to remove additional tissue because of biopsy results, you may report the subsequent excision with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended to the appropriate excision code.

Example: The surgeon suspects squamous cell carcinoma and excises the lesion in the office. The pathology report returns later showing positive margins -- meaning that the surgeon did not remove all the malignancy and must excise additional tissue. The surgeon schedules an additional excision for wider margins in the OR and takes a frozen section. This time the pathology report returns negative.

You should report the initial excision (for example, 11601, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm), as well as any allowable wound repair and E/M services that the surgeon provides in his office.

For the additional excision on a later day in the OR, report another excision code as appropriate to the size of the tissue removed (for example, 11604, - excised diameter 3.1 to 4.0 cm), as well as any allowable wound repair. Because the re-excision took place during the initial procedure's global period, you must append modifier 58 to the lesion excision code.

The surgeon will want to excise all malignant tissue on the first try, but if he doesn-t, he-ll have to go back as many times as necessary to ensure he has provided adequate margins.

Diagnosis tip: If the surgeon excises a malignant lesion and must re-excise the same lesion to ensure adequate margins, you should use the same diagnosis for the re-excision as you did for the initial excision, even if the pathology report for the re-excision returns negative for malignancy, according to AMA recommendations.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.