March 2, 2017

Question:
My physician removed a malignant lesion 1.0 cm of the scalp three days ago. I billed that procedure with CPT code 11621. Today we received a pathology report which indicated there were still positive margins. Should I use Modifier 59 when report the second lesion excision.

Answer:
When the margins are still positive and you re-excise the lesion within the 10-day global period you would report Modifier 58 (staged or related procedure or service during the postoperative period. If the physician waits until after the 10-day global period a modifier would not be appended to the excision code.

*This response is based on the best information available as of 03/02/17.