General Surgery Coding Alert

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), because it occurs within the 10-day global period of the first procedure.

Not 78: You should not use modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) in this case. The follow up excision is not for a complication; it for completing the procedure due to the same condition that prompted the initial procedure.

Cost impact: With modifier 58, the global period restarts, meaning that the surgeon will get 100 percent pay for the service.