Wiki excision help

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dmaec

dmaec

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In short:
Preoperative dx : perianal squamous cell carcinoma
Postoperative dx: perianal squamous cell carcinoma
Procedure: Re-excision of perianal squamous cell carcinoma

Path report came back as : no residual invasive carcinoma identified – chronic inflammation

I'm not looking for exact codes… what I'd like to know is the "HOW" would you code....:

would you code a malignant or benign lesion dx for the diagnosis?
would you code a malignant or benign CPT excision code?

And more so – do you have any references you can direct me to regarding this?

Thanks for your input!
 
Malignant IF ...

Just a wild guess ... first procedure path came back with some malignancy present in margins, hence re-excision for this procedure. Am I right?

If yes, then I would code this as excision of malignancy lesion, and use the dx from the original path report.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
thanks for the input Tessa and Debra - I agree - (and yes Tessa, you're correct, first report came back malignant, that's why they did the re-excision) I want to code it as "malignant" because that's what it was when they went to RE-excise it... that's WHY they did the re-excision..

so, would you use a excision of malignant CPT or a excision of benign CPT code for the procedure? (oops, never mind, I see where you wrote you'd use the excision of malignant lesion CPT) THANKS!

as for me, I want to code the dx malignant, and the CPT using the excision of a malignant lesion.

others, insist that since the path came back benign, it should be a benign CPT with a benign DX secondary to the malignant DX... and of course, can I find any of my info on this such issue? noooooooooooooo of course not! :(
 
There was a CPT assistant on this but it is several years back, I remember reading it when I worked in the reseach center and that was early 2000, so see if you can locate that. Maybe look to see if it is referenced under the malignant excision codes. Or it may have been a coding clinic. But it was one of those publications.
 
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