biopsy vs excision

mjl903

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The doctor codes the procedure as a biopsy of a uncertain lesion. I wait until the report comes back to code the diagnosis.
However, if the speciman comes back as benign or malignant with margins cleared, should I (or can I) change the CPT to excision? If I do make this change, does the doctor need to addend the notes to reflect this or is the path report stating cleared margins enough?
 

armen

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The doctor codes the procedure as a biopsy of a uncertain lesion. I wait until the report comes back to code the diagnosis.
However, if the speciman comes back as benign or malignant with margins cleared, should I (or can I) change the CPT to excision? If I do make this change, does the doctor need to addend the notes to reflect this or is the path report stating cleared margins enough?
I think you have to bill what is documented in Dr's Op report. if he did a biopsy and as coincidence margins are cleared it does not mean he did an excision of lesion :) what if margins would not be clear? then you would bill biopsy and then excision after that? This is just my opinion.
 

mitchellde

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Many people get the definitions of this confused it is dependent on the documentation and not the codes selected by the provider, a biopsy is a removal of a piece of the lesion and an excision is to take the entire lesion to a depth of full thickness, a shave is a removal of the lesion to a depth of partial thickness, sometimes a provider uses a punch which is typical for a biopsy, however if the lesion is small enough they can remove the entire lesion with the punch, they then mistakenly select this as a punch biopsy when it is by definition an excision with a punch technique. There for you can never change a code from a biopsy to an excision when a biopsy is what is documented, you need to look at the procedure note to determine the correct code.
 

mjl903

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This is my point. The doctors tend to code almost every procedure of a lesion as a biopsy when it should be a removal. Their argument is they don't know that they have removed the entire lesion until the pathology report comes in. They don't want to document removal if the margins aren't clear. Can I give them the option to addend the report if the pathology report comes back with clear margins?
 

mitchellde

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Tell them it is based on removal of the visible lesion.
this will help I understand what they are saying but they misunderstand the codes. an excision is the entire visible lesion to a depth of full thickness.
 

mjl903

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I have and other coders before me have, they just won't budge. To me if the path reports keep coming back as margins cleared it might be a red flag that they are documenting the procedure incorrectly.
 

mitchellde

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Even if the margins are not clear it would be an excision if the intent had been to remove the entire lesion, by taking all that they could see. then if they needed to do another excsion it would be a re excision due to positive margins, it is done all the time. It would be incorrect to code a biopsy just because the margins were positive when the documentation would clearly support an excision.
 

mjl903

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So what you are saying that even if the margins are clear per the path report, if they state biopsy (even to confirm a diagnosis) I should just code it as a biopsy and let it go, even if almost everything they document is a biopsy? Don't you think this is a red flag???
 

armen

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So what you are saying that even if the margins are clear per the path report, if they state biopsy (even to confirm a diagnosis) I should just code it as a biopsy and let it go, even if almost everything they document is a biopsy? Don't you think this is a red flag???
Red flag would be to bill something that is not documented. If doctors states biopsy then its a biopsy.
 

mjl903

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Thank you, that is what I have been doing, I just wanted to be sure. I appreciate your patience and answers!:)
 

mitchellde

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If the documentation is descriptive of a biopsy by definition even with clear margins then it is a biopsy, if the documentation is descriptive of an excision then you code an excision if if the the margins are not clear.
 
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