When there is an wide re-excision of a 1.9 mm beslow melenoma, how do you determine the wide excision size when it is not mentioned?
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Resolved 1.9 mm breslow melenoma
- Thread starter KathyP_3146
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Lori
Well-known member
To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append a modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure.
If it was a separate operative session & the provider only documents the margins & the original lesion is no longer there it was excised out and the edges pulled together and stitched for example think of it as a straight line and now he is re-excising from that line 1.9 cm on each side so you have an excision of 3.8cm.
If it was the same operative session you may need to query if you do not have all the information in the record.
CPT states "When frozen pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision (s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append a modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure."
Please see this thread on lesions for more.
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If it was a separate operative session & the provider only documents the margins & the original lesion is no longer there it was excised out and the edges pulled together and stitched for example think of it as a straight line and now he is re-excising from that line 1.9 cm on each side so you have an excision of 3.8cm.
If it was the same operative session you may need to query if you do not have all the information in the record.
CPT states "When frozen pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision (s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append a modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure."
Please see this thread on lesions for more.
Resource - Lesion Coding
AAPC recommends these 5 steps: Step 1: Measure First, Cut Second Step 2: Wait for the Pathology Report Step 3: Location Matters Step 4: Bundle Simple Repairs with Excision Step 5: Report Each Lesion Separately https://www.aapc.com/blog/44947-lesion-excision-5-steps-to-coding-success/...
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