Wiki ICD-9/CPT help...

[cmedina969800]

I need some opinions on how to "correctly" code this scenerio.

We had a visit and a shave biopsy was done. Path came back w/ diagnosis of Basal Cell Carcinoma of the nares.

Three weeks later, the patient comes in to have a deep cut excision done to make sure all the Basal Cell Carcinoma is removed. Path came back as "benign epidermal inclusion cyst."

How would you code this?

Any and all suggestions are appreciated

 

[mitchellde]

the indication for the second procedure was the basal cell CA, the excision of the remaining basal cell also included a benign inclusion cyst is what it sounds like I would code the Basal cell CA with a malignant excision CPT and like the two together, you can code the benign cyst as a secondary dx code but do not link it to the procedure. it is an incidental finding and is not the reason nor the medical necessity for the procedure.

 

[cmedina969800]

Thank you so much for your opinion. That is exactly what I was thinking but I wanted to make sure