Wiki benign removal

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misstigris

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When a patient has a removal of a benign lesion (whether it is shave, biopsy, or excision) is there an additional code you can add to show it was medically necessary due to its change in size or color? I know there are supporting codes you can add to show inflammation, bleeding, etc

The documentation in the progress note has this clearly documented. The lesion was sent to pathology and and came back benign.
 
I use V71.1 for observation and eval of a suspected malignant neoplasm not found. It is first-listed only allowed and then use the benign code second.
 
The rule is that you should always code the diagnosis from the pathology report. When my docs code for an excision of an unspecified lesion because it looks suspicous but it comes back benign we code from the 216 series. If the lesion is symptomatic we through in the 782.9. I have never tried using the v71.1 code but that sounds like a good idea too. I took the CPCD course and exam and they never mentioned the V71.1.
 
I worked in the cancer center for many years and this was one of our favorite codes. You never use it unless you have the path report. What it helps with is those payers that want to deny benign removals as a cosmetic event. And V71.x is first-listed only allowed.
 
Thanks for that information Debra. The V71.1 code is a very good code to know because of those payors that will deny it as cosmetic.

Luz Cruz-Johnson CPC,CPCD,PCA
 
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