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General Surgery Coding Alert

Reader Question:

Coding a Lesion as Benign Or Malignant

Published on Fri Sep 01, 2000

Question: How do you code a lesion of the skin if, at the time of excision, the surgeon does not know whether it is benign or malignant?

Kay Bell
Murphy, N.C.

Answer: Waiting for the pathology report is the most accurate way to code neoplasms of the skin. This report is beneficial to the coder and reveals whether the lesion is benign or malignant. Use the size of the lesion stated in the documentation provided by the physician, as the pathology report gives only the size of the specimen, which may or may not be the same as the lesion size. There have been many instances where coders submit the lesion as benign, only to discover when the pathology report returns that it is malignant.

Lesions of the skin are identified by referencing the neoplasm table under Skin in the ICD-9 Manual, and then finding the exact anatomic site, says Linda Jackson, CPC, CCS, Medicare consultant with Iowa Veterans Home in Marshalltown, Iowa.
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