General Surgery Coding Alert
Coding a Lesion as 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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