Page History

...

Example: Patient has a needle biopsy of prostate that is positive for adenocarcinoma. The patient chooses to have a radical prostatectomy. The pathologic examination of the prostatectomy specimen shows no residual tumor. Code the radical prostatectomy.

4. Code an excisional biopsy, even when documented as incisional, when

a. All disease is removed (margins free), OR

...

Note 1: Do not code an incisional biopsy as an excisional biopsy when there is macroscopic residual disease.

Note 2: Shave or punch biopsies are most often diagnostic. Code as a surgical procedure only when the entire tumor is removed and margins meet the criteria in either 4.a or 4.b above.

Example: Shave biopsy performed for a suspicious lesion on the skin of the right arm that has been changing in size and color. The shave biopsy pathology report showed malignant melanoma with only microscopically positive margins. Code the shave biopsy as an excisional biopsy.

5. Code total removal of the primary site when a previous procedure resected a portion of the site and the current surgery removed the rest of the organ. The previous procedure may have been cancer directed or non-cancer directed surgery.

...