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 [...]