General Surgery Coding Alert

Question:  The surgeon performs a lesion re-excision for margin removal because the pathology report identifies "suspicious cells" but doesn't diagnose malignancy. How should we code the re-excision procedure?

Arkansas Subscriber

Answer: Coding the re-excision does not depend on the pathology report -- whether malignant or benign. The rules for reporting a re-excision procedure depend on whether the surgeon performs the service during the same operative session as the initial excision, or at a later time.

For instance: If the pathologist performs a frozen section and reports to the surgeon while the patient is still "on the table" that the margins are not clear, the surgeon may perform a re-excision during the same operative session. In that case, you should code for a single excision. Your size for the code selection should be "based on the final widest excised diameter required for complete tumor removal," according to CPT ®.

If the re-excision takes place at a later session, you'll need to select an excision code the same way you would for the initial excision. For benign lesions, select from codes such as 11400-11446 (Excision, benign lesion, including margins, except skin tag [unless listed elsewhere]), trunk, arms or legs; ...) based on anatomic site and measuring greatest diameter of the lesion plus margin.

Lesion excision codes include simple closure. If the re-excision requires intermediate or complex closure, you should code the service separately using the appropriate code from the range 12031-12057 (Repair, intermediate ...) or 13100-+13153 (Repair, complex ...).

Don't forget modifier: If the re-excision takes place during the post-operative period, you'll need to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Watch for medical necessity: Due to the concern for clear surgical margins to avoid the spread of cancer, lesion re-excision is far more common for a malignancy than for a benign lesion. Because the pathology report indicated "suspicious cells," you'd probably have a diagnosis code for abnormal findings, such as 792.9 (Other nonspecific abnormal findings in body substances) rather than for benign findings, since that's not confirmed. Such a code would be more likely to demonstrate medical necessity for a lesion re-excision.

Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.