General Surgery Coding Alert

You Be the Coder:

Lesion Removal

Published on Sat Apr 01, 2000

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: A lesion is removed but the pathologist cannot determine if it was malignant or benign. His recommendation is to do a wide excision to be safe. Is this coded as a malignant or benign removal?

Margie Pfaff, CPC
Wisconsin

Answer: Because the status of the lesion is uncertain, the general surgeon should use the excision of benign lesion code (114xx), says Karen Evans, RN, CPC, a coding and reimbursement specialist in Mount Vernon, Wash., noting that a diagnosis of uncertain behavior should be included. The wide excision also should be coded 114xx , and should be appended with a -58 modifier (staged or related procedure or service by the same physician during the postoperative period) to indicate that the second procedure was staged because it occurred during the postoperative period of the first procedure.

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