tci General Surgery Coding Alert - 2004 Issue 2

Reader Question: Three Steps for Excision/Biopsy Coding

Question: Our surgeon obtained a partial incisional biopsy followed by excision of the same lesion. Should I report the biopsy, the excision, or both?Oregon Subscriber Answer: Generally, biopsy is included in excision of the same lesion, but it's easy to get confused. To sort through the confusion, follow three basic rules: 1. If the surgeon performs incisional biopsy on a lesion or lesions, but does not remove any lesions completely, claim only the biopsy(s). 2. If the surgeon performs incisional biopsy on a lesion or lesions and follows by excising the remainder of the lesion(s) immediately (as...

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