tci General Surgery Coding Alert - 2003 Issue 2

You Be the Coder: Categorize Uncertain Lesions as Benign

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer. Question: Our surgeon removed a lesion, but the pathologist is unable to determine if it is malignant or benign and has recommended a wide excision, "just to be safe." How should I categorize the lesion? Georgia Subscriber  Answer: If the status of the lesion is uncertain, use the code for excision of benign lesion (114xx) and include a diagnosis "of uncertain behavior." Report the wide excision using 114xx and append modifier -58 (Staged or related procedure...

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