tci General Surgery Coding Alert - 2000 Issue 8

Case Study: Documentation is Key to Getting Paid for Excision of Lesions

When surgeons remove multiple benign lesions from a patient, each excision should be billed separately, depending on the size of the lesion and its location on the body. If more than one similarly sized lesion is removed from the same body category, each excision should be billed separately with modifier -59 (distinct procedural service) attached, coding experts say. In the following operative report, the surgeon removed 16 nevi from a 40-year-old (non-Medicare) patient with dysplastic nevus syndrome. Of these, 14 were in the same category based on body area, and 10 were in the same size category. (A dysplastic...

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