tci Outpatient Facility Coding Alert - 2013 Issue 3

Reader Question: Situation Dictates Margin Re-Excision Coding

Question: The surgeon performs a lesion re-excision for margin removal because the pathology report identifies “suspicious cells” but doesn’t diagnose malignancy. How should we code the re-excision procedure? Arkansas Subscriber Answer: Coding the re-excision does not depend on the pathology report — whether malignant or benign. The rules for reporting a re-excision procedure depend on whether the surgeon performs the service during the same operative session as the initial excision, or at a later time. For instance: If the pathologist performs a frozen section and reports to the surgeon while the patient is still “on the...

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