General Surgery Coding Alert

Nugget: If a surgeon excises more tissue to remove margins and the lesion turns out to be benign, wound closure may be billed in addition to the lesion excision.
To accurately bill lesion excisions, general surgery coders need to (as always) carefully talk to their surgeons, carefully read the operative report, and wait for the pathology report before submitting claims, coding experts say. In particular, waiting for the pathology report is crucial, because only then does the surgeon know for certain whether the lesion is benign or malignant.
 
The excision of a malignant lesion is reimbursed at a higher rate than that of a benign lesion because (1) the general surgeon is likely to excise more tissue to remove the margins of the lesion; (2) there is an inherent risk to the patient if all the cancerous tissue is not removed; (3) the surgeon likely will spend time counseling the patient; and (4) often more needs to be done to prevent the cancer from metastasizing further.
 
General surgeons typically make a clinical assessment as to whether a lesion is benign or malignant before excising the lesion. If a malignant lesion is suspected, the general surgeon probably will excise a larger tissue sample in an effort to get at the lesion's margins.
 
Determining how to code the excision, however, is another matter. Marc E. Hernandez, MD, a general surgeon in Inverness, Fla., describes the process (and the problem) as follows:
On occasion, we will see patients to evaluate skin lesions to make an evaluation and recommendations regarding whether they are benign or malignant. Many patients request excision of these lesions.
 
Based on a clinical assessment of whether a lesion is benign or malignant, we perform an appropriate excision. For lesions that clinically appear benign, we in general will make a smaller, more superficial excision with suture closure. For lesions that clinically appear malignant, we make a wider excision with more attention to margins and depth of excision. The specimen is then sent for pathology. The pathology report routinely takes two working days.
 
The question is how to code for the initial excision. Since the extent of excision is based on a clinical diagnosis, one could argue for billing excision of a malignant lesion if the clinical diagnosis and subsequent excision are consistent with a malignant lesion. However, the pathology report sometimes returns two days later with a benign lesion. Because of the delay in the pathology report, one could consider not billing for the lesion as excision of a malignant lesion or a benign lesion until the pathology report returns. [...]