Health Information Management

Tip: Know what documentation is necessary to code tumor excisions

APCs Insider, January 29, 2010

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The AMA made a significant number of changes to soft tissue and bone tumor excision codes for 2010. The new and revised codes categorize these tumor excisions by size of the tumor and by level of depth. Coders need enough accurate documentation to correctly code the procedures with the new levels of specificity. Physicians should answer the following questions clearly in their documentation:
How deep is the actual resection? The deepest layer of the resection will determine the correct code. If the excision goes only to the integumentary system, don’t use the musculoskeletal codes, use integumentary codes.
How complex is the procedure? Physicians must clearly indicate whether the procedure was an excision or resection. They also must specify whether the excision was radical, extensive, or simple.
What type of closure was performed? Remember that you can code only complex wound closures, not simple or intermediate. Coders also must look for documentation, noting any additional procedures the physician performed, and determine whether those are also billable.
How large was the excision? Size matters when selecting the proper code for tumor excisions, so ensure that the physician has documented the size of the excision.
This tip is adapted from “2010 CPT: Tumor excisions, facet joint injections among most significant changes” in the February issue of Briefings on APCs.

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