Biopsy vs excision

kb26coder

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My physician biopsied a lesion and the pathology came back positive as "basal cell carcinoma, completely excised." He now wants to go back and change the charge from a biopsy to an excision of a malignant lesion, even though the original dictation says the lesion was "excised and biopsied."

I've seen other situations where they biopsy a lesion and do an ED&C at the same time, but we usually wait for the pathology to come back before putting the charges through. Is this workable or even ethical? Any thoughts would be welcome!
 
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Biopsy vs Excision

When a physician excises a lesion completely, the lesion is destroyed and it is no longer considered a biopsy. Routinely, the excised lesion is sent to pathology for examination and the obtaining of the excised lesion is not considered a separate biopsy procedure. Therefore, the biopsy procedure code should not be reported.

The physician cannot change the documentation from "excision of a lesion" to "excision of a malignant lesion" just because the pathology report indicated malignant after the fact.

The "basal cell carcinoma" would be a final diagnosis, while the "lesion, unspecified" would be the diagnosis for that encounter. The physician would have no idea if the lesion was benign or malignant at the time of excision until the path report was received.
 

DeeCPC

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I agree with Tonya. Follow the original intent which was a biopsy.

I discourage providers from changing anything already documented just for better reimbursement.
 

mitchellde

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it was either a biopsy OR an excision at the time it was performed and does not change with the path report. A biopsy is a removal a piece of the visible lesion and an excision is a full thickness removal of the entire visible lesion. So even if he says it was a biopsy (which is a term often used incorrectly) the coding is based on what was performed by the description. So on the original op note what was dictated at the time is what must dictate the type of procedure and the code.
 

kb26coder

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Yeah, that's pretty much what I originally figured and is what I told the physician. I appreciate everyone's input!
 

Corinac

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What would you do: On this same topic, what if the provider documents complete excision and it has been billed as an excision rather than a biopsy and the path report comes back with one margin, so it is not completely excised? Addendum and corrected claim?
Corina
CPC, COC
 

CodingKing

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What would you do: On this same topic, what if the provider documents complete excision and it has been billed as an excision rather than a biopsy and the path report comes back with one margin, so it is not completely excised? Addendum and corrected claim?
Corina
CPC, COC
Its still an excision because the intent was to fully remove. The fact that procedure failed doesn't turn it into a biopsy.
 
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