AAPC - Back to school
Results 1 to 3 of 3

Thread: Diagnosis Code for 2nd Surgery

  1. #1

    Default Diagnosis Code for 2nd Surgery

    AAPC: Back to School
    One of my oral surgeons did a wedge resection of the lower lip on a patient. The pathology report showed the lesion was malignant and extended into the margins of the specimen. My surgeon, of course, scheduled the patient to return so he could excise the remainder of the malignancy. The second procedure included a wedge resection and vermillion lip shave. Due to holidays and the patient's schedule, there was a gap of about a month between the 1st and 2nd surgery. In the interim, our staff billed the 1st surgery to Medicare. The 2nd surgery path reports did not show a malignancy. My doctor wants me to be sure to bill the 2nd surgery with a diagnosis code to show that it was related to the 1st one even though no malignancy was found. What codes would anyone suggest to accomplish this task? I was thinking of personal history of neoplasm but I'm just not sure that is correct. I'm having a major brain freeze on this one so all assistance is greatly appreciated!

    Jennifer, CPC

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    you use the malignancy for the 2nd surgery since the original path indicated the malignancy extended into the margins. That means the malignancy still existed for the patient so the 2nd surgery was to remove the remaining malignancy. The path for the 2nd surgery is only confirming for the provider that the malignancy is now successfully removed.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    durham, nc


    I agree with Debra, you would still use the malignancy code for the 2nd surgery.
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

Similar Threads

  1. 2nd Line On A Surgery Claim
    By ShelleyM in forum Modifiers
    Replies: 2
    Last Post: 04-17-2014, 11:53 AM
  2. 2nd Line On A Surgery Claim
    By ShelleyM in forum Ophthalmology/Optometry
    Replies: 0
    Last Post: 04-15-2014, 11:35 AM
  3. Replies: 2
    Last Post: 11-04-2013, 09:30 AM
  4. Diagnosis code for Surgery consult
    By catharine in forum E/M
    Replies: 2
    Last Post: 03-23-2013, 10:17 PM
  5. outpatient surgery first diagnosis code
    By territheriot in forum Diagnosis Coding
    Replies: 1
    Last Post: 05-08-2009, 12:26 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.