Benign or Malignant?

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Surgery on a patient who had a previous malginant lesion removed. She returns for unclear marigns. However it turned out to only be scar tissue; there was no malignancy. Her diagnosis code is malignancy, skin; her pre-op and post-op dx are the same.

Need help with the CPT code -- would you do removal of benign or malignant skin lesion? I am leaning towards benign, but then it won't match the ICD dx codes.

Thanks
 

eadun2000

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Surgery on a patient who had a previous malginant lesion removed. She returns for unclear marigns. However it turned out to only be scar tissue; there was no malignancy. Her diagnosis code is malignancy, skin; her pre-op and post-op dx are the same.

Need help with the CPT code -- would you do removal of benign or malignant skin lesion? I am leaning towards benign, but then it won't match the ICD dx codes.

Thanks
Would love to hear what others say, however, will give you my opinion. The malignancy has already been excised, but margins were not clear, so the physician excises more tissue from around the edges. When he did this, he did it for a malignant lesion. Therefore, I would code as excision of malignancy not benign. But as I said, I would also like to see what others think.
 

AB87

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I agree with that statement.. "unclear" in my mind stands for there is still some malignancy left
 

mitchellde

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There is a CPT assistant from several years back that states when the margins are unclear and a re-excision is performed then the dx is the malignancy.
 
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Thank you all for your help! My boss and I have been trying to decipher what option is best; the pathology was negative, so we were very unsure, but we could justify both ways of coding. Thanks again for all the help:)
 
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