CPT and Diagnosis Codes for a Skin Lesion

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May 31, 2012

Question:

A patient was sent to us by another provider who had a biopsy proven pathology report showing a basal cell carcinoma. We removed additional margins and the pathology report came back benign for us. We are confused about whether we should report the CPT and diagnosis codes for a malignant or benign lesion since we did not do the original biopsy.

Answer:

This is a very good question! Because you have a previous positive pathology report, even though it is from a different physician, then you may report your procedure using the excision of malignant lesion CPT code (e.g., 116xx) and a malignant skin neoplasm diagnosis code.