AHA Coding Clinic® for HCPCS - 2013 Quarter 1; ASK the EDITOR
Radical excision vs. wide excision
Patient had a previous excisional biopsy of the mid-upper back. This proved to be a poorly differentiated possibly metastatic desmoplastic spindle cell melanoma into the soft tissues of back. The patient now presents to have excision of the scar and surrounding tissue, subcutaneous tissue and fascia overlying the muscle in order to adequately control the disease. The 13 cm x 2 cm wound was closed in layers with buried dermal sutures, skin closed with 4-0 Monocryl with Dermabond also being utilized. Pathology report shows seborrheic keratosis with no residual spindle cell malignancy identified. Would this be considered a radical excision or a wide excision of a previous scar? ...
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Article Overview
This article addresses a surgical coding question involving an excision performed after a prior biopsy for a malignant-appearing lesion on the back. It explains why the documentation must be reviewed carefully and why the surgeon may need to be queried to determine the correct classification of the excision. The piece is useful for coders, auditors, and clinical documentation staff working with excision procedures and postoperative pathology findings.
Why This Topic Matters
The distinction affects accurate surgical coding and compliant claim reporting when operative notes and pathology results do not clearly establish the nature of the excision.
What You Will Learn
- How to approach an excision coding question when prior biopsy and current operative findings differ.
- Why incomplete or ambiguous operative documentation may require provider clarification.
- How pathology results can factor into review of a surgical excision case.
- What types of documentation issues can affect classification of an excision procedure.
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Physician office staff
- Outpatient surgery billers
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