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Diagnosis Code for 2nd Surgery

  1. #1
    Default Diagnosis Code for 2nd Surgery
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    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
    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
    I agree with Debra, you would still use the malignancy code for the 2nd surgery.
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

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