General Surgery Coding Alert

Question: Our surgeon's card merely noted that he performed a "wide excision" biopsy of sarcoma, without providing any exact measurements. Which excision code should I use?

Rhode Island Subscriber
Answer:  The correct answer depends on the documentation in the operative report. Relying on the surgeon's card without checking the operative note often results in coding errors.
 
Most sarcomas are neoplasms of soft tissue or muscle or bone; less frequently, the surgeon may excise a skin sarcoma. Therefore, it is likely that the correct code would be an excision of tumor code in the Musculoskeletal System section (20000 series) of CPT. Coders often overlook this section when a deep biopsy is performed and, instead, go straight to the Integumentary System section (10000 series).
 
Tumor excision codes are found throughout the Musculoskeletal System section, listed anatomically. Two or three codes may describe a tumor excision in any particular anatomic area, depending on whether the tumor is subcutaneous or deep, subfascial or intramuscular.
 
The fact that the surgeon noted a "wide excision" (the large margin around the tumor that is taken when the tumor is biopsied or excised) has little relevance from a coding standpoint. A wide excision cannot be coded correctly until it is adequately documented; therefore, only a subcutaneous (soft tissue) excision should be billed in this case.
 
If your surgeon says that this was a re-excision of a skin sarcoma, then you would code the excision of a malignant skin lesion (11600-11646) according to the size of the original lesion removal. When a skin sarcoma is excised, the surgeon should record the size of any lesion excision; without such documentation, only the smallest appropriate excision code may be used if the claim is sent before the pathology report returns. Although the pathology lab will report the size of the excised lesion as smaller than it was originally, it will probably still be larger than the smallest appropriate code.
 
To further complicate the situation, a lesion may be re-excised, and some sort of tissue transfer or rearrangement (14000-14350) may be performed. These codes include the excision and the repair. This is billed by the square centimeter, so the size of all the tissue removed should be documented.