tci General Surgery Coding Alert - 2002 Issue 4

Reader Question: Wide Excision Biopsy

Question: Our surgeon's card merely noted that he performed a "wide excision" biopsy of sarcoma, without providing any exact measurements. Which excision code should I use?Rhode Island Subscriber Answer:  The correct answer depends on the documentation in the operative report. Relying on the surgeon's card without checking the operative note often results in coding errors.  Most sarcomas are neoplasms of soft tissue or muscle or bone; less frequently, the surgeon may excise a skin sarcoma. Therefore, it is likely that the correct code would be an excision of tumor code in the Musculoskeletal System section (20000 series)...

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