tci General Surgery Coding Alert - 2021 Issue Q3

Reader Questions: Go for Modifier 58 Without Complication

Question: Our surgeon excised a 1.2 cm melanoma, but returned the patient to surgery three days later for another excision measuring 1.6 cm because the margins weren’t clear. How should we code this? Nebraska Subscriber Answer: You should code the initial excision as 11602 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm). Upon return to surgery, you should code the second excision as 11602 with modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period)...

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