'Department of Health and Human services, Victoria, Australia'

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Excision biopsy of nodule in axilla

Publication Date: 2012-13 June Database

ICD 10 AM Edition: Seventh edition

Retired Date: 30/6/2017

Query Number: 2763

Patient with past history of breast cancer with wide excision and axillary dissection admitted for excision of axillary nodule.

Operation report states that the operation performed was excision biopsy of nodule in axilla. Body of report states 'incision through medial part of scar. Lump excised with some surrounding tissue. ? suture granuloma, ? recurrence. Small pea shaped nodule. Closed with 3.0 interrupted vicry and interrupted subcuticular monocryl to skin, steristrips and opsite'.

Histology finds the axillary nodule to be a traumatic neuroma.

Should the procedure code for the excision of the nodule be 31205-00 [1620] Excision of lesion(s) of skin and subcutaneous tissue of other site, as this fits the description of the procedure on the operation report before it was known what the nodule was, or should the procedure code be 39324-09[80] Removal of lesion from superficial peripheral nerve, following the pathway of excision, neuroma etc.

Should the histology results be used to determine the code for the procedure in this case, or should the procedure be coded as per its description, where there was no mention of any nerve.

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ACS 0010 General abstraction guidelines


Where the operation report only contains non specific diagnoses such as lesion, nodule, lump or mass and the histology is used by the coder to determine the diagnosis, VICC considers that the procedure code should correspond to the diagnosis code.

Therefore in the case cited, VICC considers the correct procedure code to assign is 39324-09 [80] Removal of lesion from superficial peripheral nerve.

For Tenth Edition advice refer to #3333 Excision biopsy of nodule in axilla published in the 2017-18 March VICC queries database.