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CODING METASTASIS

Nellie Posted Tue 16th of February, 2010 16:57:33 PM

Patient has a primary cancer of the liver 88307 with a separately submitted colon resection, with metastatic implants. I would code this colon resection as an 88309 but one of our pathologists insists that because it is not a primary tumor an 88307 is correct. The CPT description reads, colon for tumor.
Something in black and white to convince her would be a help.

SuperCoder Answered Wed 17th of February, 2010 07:15:59 AM

In this case your pathologist is correct for the CPT code 88307, because as per the report there isn't any mention of colon resection for tumor. To qualify for the CPT code 88309 the word tumor must be documented.
So I would go with the code 88307.

Coding Rule: Not documented, not done.

SuperCoder Answered Wed 17th of February, 2010 10:56:55 AM

I would go with coding 88309. Your query says "separately submitted colon resection, with metastatic implants". I think the presence of primary Ca of Liver and documentation like "colon resection, with metastatic implants" reinforces the evidence of presence of tumor (secondary Ca) in Colon and the resection of colon as a result of that.

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