If a procedure's CPT code is assigned for a benign lesion but the pathology report identifies it as malignant, can the claim be submitted using the assigned code?

The scenario presented involves the appropriate coding of a procedure when there is a discrepancy between the initial CPT code assigned and the findings of the pathology report. In this case, if a procedure's CPT code was originally assigned for a benign lesion, but pathology later identifies the lesion as malignant, the claim cannot be submitted using the originally assigned code.

This is primarily because CPT codes provide a standardized means of describing procedures and services in a way that can be universally understood. The assignment of a CPT code for a benign lesion indicates that the expectation was that the outcome would match that classification. However, once the lesion is reclassified as malignant based on pathology results, the implication is that the nature of the procedure—and potentially the treatment required—has changed. This calls for the use of a specific CPT code that reflects the malignancy, which may have different implications for reimbursement and clinical management.

Accurate coding is crucial for compliance with healthcare regulations and helps ensure that providers are reimbursed correctly for the services they provide. Therefore, using a code that reflects the pathology report, which indicates malignancy, is essential for correct documentation and processing of the claim.