Wiki neoplasm skin uncertain behavior & re-excision

[SLA*72]

Hello,
I have been taking the coding class to obtain my CPC and also work in a billing/coding office and run across this often. If a pathologicial report states atypia and needs re-excision to better determine a diagnosis of the specimen....how does that get ICD 9 coded with 238.2 as this particular report states :" showed architectural atypical....dysplatic junctional nevus..." . Also, when coding the CPT as this was a biopsy of 11100, if there is re-excision does the initial biopsy get coded? Does a subsequent removal get coded, if outside the global period? I cannot find this in searching the online coding tool that is utilized at my job, Encoder Plus online, I cannot even find an article in Coding Clinic nor CPT... (it may be my wording that I am plugging in! ) and hoping that some of you can help me. I would really appreciate any insight.
Thank you!

 

[mitchellde]

If you are doing the re excision in a different session then you code with the 238.xx dx and an excision code the original bx code stil gets submitted. If the re excision is performed in the same session due to a quick frozen section then you code only the re excision. If they are performed on the same day but 2 different sessions then you code both and use the 58 modifier on the re excision.

 

[SLA*72]

Thank you! So code the original biopsy with uncertain or no? Does the original biopsy go in as benign due to the dysplastic nevus dx on the orginal path?

 

[mitchellde]

Use the 238 if the path stated that is was a architectural atypical....dysplatic junctional nevus, I assumed you were leaving out extraneous terms and not talking about 2 different specimens.

 

[SLA*72]

Appreciate your help with the uncertain behavior skin

Yes, sorry, it was just one. You have helped me so much. I appreciate your time. Thanks!!

 

[SLA*72]

uncertain behavior skin answered

Yes, sorry, it was just one. You have helped me so much. I appreciate your time. Thanks!!
Stephanie