tci General Surgery Coding Alert - 2006 Issue 8

Reader Questions: 'Uncertain' ICD-9 Means 'Benign' CPT

Question: The pathologist was unable to determine if a lesion the surgeon removed is malignant or benign. The pathologist has recommended an additional wide excision, -just to be safe.- How should I report this?North Carolina Subscriber Answer: For a lesion of uncertain behavior, code for excision of a benign lesion (11400-11471) and include a diagnosis -of uncertain behavior- (for example, 238.3, Neoplasm of uncertain behavior of other and unspecified sites and tissues; breast). Report the later wide excision using 114xx and append modifier 58 (Staged or related procedure or service by the same physician during...

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