Ob-Gyn Coding Alert

Question:My ob-gyn removed a second lesion. The path reported severe dysplastic junctional melanocytic nevus exhibiting severe architectural disorder and melanocytic cytologic atypia with features of regression extending to the section edge. He noted that "Re-excision is required" Should I bill from the 11600-11646 series? The first lesion removal was billed as benign.

Tennessee Subscriber

Answer: This is still not cancer, but the ob-gyn still needs to remove this type of lesion because it puts the patient at risk for developing melanoma. Remember, you should always be cautious when applying a cancer diagnosis to a patient's claim, because this may affect her future insurance.

You should use the benign excision codes for this (11420-11426 series) unless the physician documents a wide excision. Per CPT®, if the physician performs a wide excision, you can report the malignant excision codes. You will also add modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) for the re-excision.

The actual CPT® code you select will depend on where it was located (e.g., genitalia, trunk, etc), and the size of the removal based on the largest diameter. Most nevi are found on the skin, so your diagnosis code could be a benign lesion of the skin or a lesion of uncertain behavior with this diagnosis.

You should check with your physician before assigning the uncertain behavior code (for instance 238.2, Neoplasm of uncertain behavior, skin).

ICD-10: When your diagnosis system changes, you'll report 238.2 as D48.5, neoplasm of uncertain behavior of skin.