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How to code?

  1. #1
    Overland Park, KS
    Default How to code?
    Medical Coding Books
    Here is the scenario: A pt presents to our office for lesion removal that the providers suspects may be malignant. The provider removes the lesion and sends it off to pathology for determination. Normally, we would wait for the path results to come back and then code based on the results, but we have a corporate policy that states that all notes and superbills must be completed within 24 hours of the visit.

    How do the providers code for the above procedure? Would they code for excision of a benign lesion since at this point they don't know it is malignant?

    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    Columbia, MO
    You cannot code this without the pathology because while we could give it a dx code of 709.8 you still cannot assign the CPT code. Remember this is NOT a neoplasm unspecified or uncertain, it is just a skin lesion until path tells you something else. There is a CPT assistant on this and the very fact that the CPT codes themselves specify benign or malignant only status, none of them say excision of lesion with unknow path results. If the path comes back benign then you can use V71.1 as your first list dx.

  3. #3
    Overland Park, KS
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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