Wiki Skin re-excisions

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kduty

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Our clinic is conflicted on the appropriate way to code the pathology report on a follow-up excision after a diagnosis of carcinoma. Some of us say we should code the carcinoma even if it says "no residual..." and some of us say no. Please help us solve our dilemma!

Skin, right mastoid, excision:
- No residual basal cell carcinoma. (C44.41)
- Epidermal reparative change and dermal scar, consistent with biopsy site. (L90.5)
 
I code these as the L90.5 with the Z code for history of neoplasm of skin. You cannot code the neoplasm when the path report does not support that diagnosis.
 
Pathology re-excisions

Hello Debra

We are having this issue as well in my facility. My dermatologist coder thinks we should default to the CX Dx code, which I agree from the procedure end of things. However I am the Pathology coder. My Path report reads, Re-excision of Malignant neoplasm, No residual tumor identified, reparative changes present. Example incidental SK

I believe I should be billing according to the Path report so would report the SK in this situation and Personal history of the Malignant neoplasm (Z) code, since it says no residual tumor identified???

Do you have a area of guidelines I can acquire for this situation also

Thank you for your help

Renae G
 
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