Wiki Help with report


True Blue
Marrero, LA
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Patient was booked as a benign lesion 11403 with a diagnosis as 239.89 unspecified morphology and behavior. Now path report comes back as Back mass- metastatic aenoid cystic carcinoma (3 CM) . Patient had a history of adenoid cystic carcinoma with metastasis to chest wall and lung. Now one coder says leave it as 11403 with diagnosis as it was 239.89, but I disagree. I think it should be 11603 for cpt but not sure on diagnosis , would it be 198.89 ? Here is report ,tHANKS


PROCEDURE PERFORMED: Excision, right back mass.

OPERATIVE PROCEDURE: The patient was brought to the operating room and placed on the table in a supine position, then placed in a left lateral decubitus position. He was then prepped and draped around his area on his chest wall posteriorly and to the right. An incision was made overlying the mass after the skin and subcutaneous tissue was infiltrated with 1% lidocaine and 0.25% Marcaine, 50:50 solution. This was deepened, circumferentially excised, removed, and sent to pathology for analysis. Hemostasis was obtained with electrocautery. The wound was then closed in layers with absorbable suture. Steri-Strips were applied as well as the bandage. The patient was awakened and transported to the recovery room in satisfactory condition.
Any time we have an excision, we wait for path to come back before we bill. I believe that is how most everyone does it. At least this is what I think.:)

So I would go with the 11603 and the specific Dx code.