Oral Surgery Coding & Reimbursement Alert

Question: Our surgeon recently performed biopsy in the area of the floor of the mouth for a 59-year-old male patient. The patient was initially diagnosed with squamous cell carcinoma which our surgeon resected and repaired using a graft. Since the patient had irregular areas from the resection, our surgeon performed biopsy of these areas. What code should I report for the procedure that was performed and should I report this procedure with any modifiers?

Vermont Subscriber

Answer: First and foremost, you have not mentioned when the patient was recalled for the second procedure. When your surgeon initially performed the resection of the lesion of the floor of the mouth, you would have reported the procedure with 41116 (Excision, lesion of floor of mouth). This CPT^® code has a 90-day global period.

If the biopsy that your surgeon performed was within the global period of the first procedure, and if your surgeon had planned to perform the second procedure then you will have to report the biopsy procedure with a modifier appended to the biopsy code. The modifier that you will use in this case will be 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). So, if the biopsy was performed within the global period of the first procedure, then you will have to report 41108 (Biopsy of floor of mouth) for the biopsy with the modifier 58 appended.

But, if the biopsy was performed after the 90-day global period following the resection, then you will only report 41108 for the biopsy without appending any modifiers to the code.  

---