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help with coding for a re-excision

  1. #1
    Default help with coding for a re-excision
    Medical Coding Books
    I am now coding for excisions etc... i've been out of it for awhile and ran across a note for a re-excision outside the global period. The note states:

    Re-excision of a BCC with positive margins. Within the body of the note the provider only documents the margins which is 4 mm= 0.4 cm. I have some paperwork that states: Re-excision of the same site to obtain wider margins is coded as if teh original lesion is still there. So I am thinking I would code for the same diameter of the lesion that was previously there and add the margin the provider has stated as 4 mm.

    Am I thinking correctly or does the provider have to state the diameter within this re-excision?

    Any help, links etc... would be greatly appreciated.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  2. Default Coding for re-excision
    Hi
    Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). Hope this helps.

    Lori M.

  3. Default Coding re-excisions
    Hi Roxanne...important to clarify ..if the surgeon allows a margin of 4mm (0.4 cm) on all sides, you would add the diameter of the lesion and double the width of the narrowest margin (0.4 cm x 2= 0.8 cm) for a total of 1.2 cm


    Lori

  4. #4
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    Default
    If the provider only documents the margins in the note then where are you getting the original lesion size? You are not allowed to pull that information from an earlier procedure note or path report. Also the original lesion is no longer there it was excised out and the edges pulled together and stitched so think of it as straight line and now he is re-excising from that line .4cm on each side so you have an excision of .8cm

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Quote Originally Posted by rthames052006 View Post
    I am now coding for excisions etc... i've been out of it for awhile and ran across a note for a re-excision outside the global period. The note states:

    Re-excision of a BCC with positive margins. Within the body of the note the provider only documents the margins which is 4 mm= 0.4 cm. I have some paperwork that states: Re-excision of the same site to obtain wider margins is coded as if teh original lesion is still there. So I am thinking I would code for the same diameter of the lesion that was previously there and add the margin the provider has stated as 4 mm.

    Am I thinking correctly or does the provider have to state the diameter within this re-excision?

    Any help, links etc... would be greatly appreciated.
    Here is what CPT says "When frozen pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision (s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append a modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure."

    Hope this helps.

  6. #6
    Default
    Quote Originally Posted by mitchellde View Post
    If the provider only documents the margins in the note then where are you getting the original lesion size? You are not allowed to pull that information from an earlier procedure note or path report. Also the original lesion is no longer there it was excised out and the edges pulled together and stitched so think of it as straight line and now he is re-excising from that line .4cm on each side so you have an excision of .8cm
    Correct, the provider only documented the margin of 4 mm. What you are saying is now making sense. Thank you for the tip!
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  7. #7
    Default
    Quote Originally Posted by eadun2000 View Post
    Here is what CPT says "When frozen pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision (s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append a modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure."

    Hope this helps.
    Yes- I read the above info in my CPT book as well but I was still a bit confused.... Thank you to all who replied.

    I believe I need to find some workshops on this topic to get myself up on things again...
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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