tur bladder tumor incomplete

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Dickson, TN
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we had a case where the surgeon was resecting a large 7 cm bladder tumor. during the exploratory part he mentioned poor visibility due to urine being bloody. as the resection was going on there has more bleeding and the resection was terminated due to extremely poor vision. The pathology show carcinoma. so eleven days later he goes back to retrieve the rest of the tumor that had been left. in the second note it is estimated that 20% of the total tumor was still there. and an additional tumor was removed. Would I bill the first excision as a lesser size or an incomplete large tumor resection and then the same large tumor resection on the second one.
Your help is greatly appreciated
Debbie
 

mbort

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2,338
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ENGLEWOOD/DENVER
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I would code out the first one based on the size of the tumor that he actually was able to capture. The case was essentially complete, he just didnt get all of it. On the 2nd case you are already going to have to modify it with the -58 modifier.

my two cents :)
Mary
 
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