Wiki malignan/benign lesion removal

[annielou]

A doctor excises a skin lesion which the pathology determines is malignant and close to the borders. He brings the patient back in for a wider excision to be sure the malignancy is completely removed. The path report of the second excision comes back completely benign. Do you code a malignant neoplasm removal or a benign on the second surgery?

 

[mitchellde]

Malignant is the dx for the second excision. The path is reading the margins as benign to tell the physician that no further excision is necessary. But the Medical necessity is that we needed to perform the excision due to a malignant pathology.