Otolaryngology Coding Alert

Question: There are two possibilities when performing surgery for carcinoma of the skin with fresh frozen pathological examination for margins. Obviously, the time spent by the surgeon in the operating room and the amount of work performed are different in each scenario. Are the two situations coded the same?

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 Answer: One possibility is that the lesion has been completely removed and the reconstruction is performed.
 
The other possibility is that a margin of the lesion is positive for residual carcinoma and has to be re-resected, sometimes more than once, before recon-struction can occur. 
 
Any re-excisions performed at the same site during the same session would typically be coded once, based on the size of the lesion removed. The repair, however, is coded based on the size of the final defect, after the original excision and re-excision(s) are performed.
 
If the re-excision is performed on a different day, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be used if the second excision falls within the global period of the first (most lesion excision procedures have a 10-day global period).
 
If the lesion removal is bundled with the reconstruction (i.e., simple repairs and adjacent tissue transfers), it may be appropriate to append modifier -22 (unusual procedural services) to the reconstruction code to indicate that the lesion removal involved much more work and time than would normally be the case.
 
Claims with modifier -22 should be submitted with documentation that clearly notes the unusual circumstances and a cover letter that requests increased reimbursement.  
You Be the Coder and Reader Questions were answered by Randa Blackwell, a coding and reimbursement specialist in the otolaryngology department at the University of Maryland in Baltimore; Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs Editorial Panel and Executive Committee; Ann Hughes, CPC, a coder with Mid-Vermont ENT; and Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wa.