Pathology/Lab Coding Alert

Question: What would be the appropriate diagnosis and procedure codes for the re-excision of a skin lesion if the re-excision shows no residual nevus identified?

California Subscriber
 
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
 
  Answer: The appropriate procedure code would be 88305 (Level IV surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair). This is the appropriate code whether it is the first or subsequent excision, because each represents a different specimen that is submitted for individual and separate examination and pathologic diagnosis.

As for the appropriate diagnosis code, that would depend on what is known about the previous excision. Your question implies that the previous excision was for a nevus. If that is known, you should code the diagnosis from the original excision as the reason for the re-excision (e.g., 216.X benign neoplasm of skin, where X denotes the site of the lesion). If the previous diagnosis is unknown, and no abnormality is found, an appropriate diagnosis may be 709.9 (unspecified disorder of skin and subcutaneous tissue).