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Carcinomas

  1. #1
    Default Carcinomas
    Medical Coding Books
    If the preoperative diagnosis is:
    1. extensive squamous cell carcinoma, right upper back.(173.5)
    2. basal cell carcinoma, left mid cheek.(173.3)
    3. squamous cell carcinoma, left medial cheek.(173.3)
    4. basal cell carcinoma, right lateral neck.(173.4)

    and the path report indicates:

    1. previously biopsied squamous carcinoma with reactive fibrosis and inflammation, excision margin free of malignancy.
    2. previously biopsied basal cell carcinoma with reactive fibrosis and inflammation, excision margin free of malignancy.
    3. previously biopsied squamous carcinoma with reactive fibrosis and inflammation, excision margin free of malignancy.
    4. previously biopsied basal cell carcinoma with reactive fibrosis and inflammation, excision margin free of malignancy.

    Would you still use the the preoperative dx since the patient is still being treated? If anybody has any information on this issue that can share, I would appreciate if you can direct me to it.
    NoRaX

  2. Default
    This sounds like a re-excision....per CPT to report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646. I would you use your pre-op. Op note does not state post-op dx also?

  3. #3
    Default
    I agree. I know I read somewhere, I think CPT Assistant, that even if the 2nd path comes back clean (on a re-excision); since the physician performed the service paying close attention to margins, due to the cancer dx, it would be coded as malignant.

  4. #4
    Default
    That's what I read too; I just needed to verify...thank you all!
    NoRaX

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