Outpatient Facility Coding Alert

Question: The surgeon performs a lesion re-excision for margin removal because the pathology report identifies “suspicious cells” but doesn’t diagnose malignancy. How should we code the re-excision procedure?

Arkansas Subscriber

Answer: Coding the re-excision does not depend on the pathology report — whether malignant or benign. The rules for reporting a re-excision procedure depend on whether the surgeon performs the service during the same operative session as the initial excision, or at a later time.

For instance: If the pathologist performs a frozen section and reports to the surgeon while the patient is still “on the table” that the margins are not clear, the surgeon may perform a re-excision during the same operative session. In that case, you should code for a single excision. Your size for the code selection should be “based on the final widest excised diameter required for complete tumor removal,” according to CPT^®.

If the re-excision takes place at a later session, you’ll need to select an excision code the same way you would for the initial excision. For benign lesions, select from codes such as 11400-11446 (Excision, benign lesion, including margins, except skin tag [unless listed elsewhere]) based on anatomic site and measuring greatest diameter of the lesion plus margin.

Lesion excision codes include simple closure. If the re-excision requires intermediate or complex closure, you should code the service separately using the appropriate code from the range 12031-12057 (Repair, intermediate ...) or 13100-+13153 (Repair, complex ...).

Don’t forget modifier: If the re-excision takes place during the post-operative period, you’ll need to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period).

Watch for medical necessity: Due to the concern for clear surgical margins to avoid the spread of cancer, lesion re-excision is far more common for a malignancy than for a benign lesion. Because the pathology report indicated “suspicious cells,” you’d probably have a diagnosis code for abnormal findings, such as 792.9 (Other nonspecific abnormal findings in body substances) rather than for benign findings, since that’s not confirmed. Such a code would be more likely to demonstrate medical necessity for a lesion re-excision.