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General Surgery Coding Alert

Reader Questions:

'Uncertain' ICD-9 Means 'Benign' CPT

Published on Sat Jul 01, 2006

Question: The pathologist was unable to determine if a lesion the surgeon removed is malignant or benign. The pathologist has recommended an additional wide excision, -just to be safe.- How should I report this?

North Carolina Subscriber Answer: For a lesion of uncertain behavior, code for excision of a benign lesion (11400-11471) and include a diagnosis -of uncertain behavior- (for example, 238.3, Neoplasm of uncertain behavior of other and unspecified sites and tissues; breast).
 
Report the later wide excision using 114xx and append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate that the surgeon staged the second procedure (the wide excision) because it occurred during the postoperative period of the first procedure.
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