Scenario:
- Procedure: Left frontoparietal craniotomy for total resection of a left frontal ring-enhancing mass.
- Operative Note: Gross total resection of the left frontal ring-enhancing mass was performed.
Question: How Would You Code This Procedure?
- 02 Diagnostic & Staging Procedure-Biopsy Primary Site
- A200 Local excision of tumor, lesion, or mass, excisional biopsy
- A210 Subtotal resection of tumor, lesion or mass in brain
- A300 Radical, total, gross resection of tumor, lesion or mass in brain
- A400 Partial resection of lobe of brain, when the surgery cannot be coded as A200-A300
- A550 Gross total resection of lobe of brain (lobectomy)
Answer: A300 Radical, total, gross resection of tumor, lesion or mass in brain
Discussion: The surgeon documented removal of the tumor/mass. There is no documentation that part or all of a brain lobe was resected. A complete tumor removal does not automatically equal a lobectomy.
Did the surgeon remove the tumor, or did the surgeon remove the lobe?
- Tumor removed = A300
- Brain lobe removed = A550
⚠️ Common Coding Pitfall: Many registrars incorrectly assign A550 when documentation supports only complete removal of the tumor.
