Communication Is Key to Code Lesion Excisions (and More)
Provider documentation does not always provide the information necessary to code with precision. For example, lesion excision codes 11400-11646 are size-based, with margins factored into the measurement. If the physician does not record the size of the margin taken, in addition to the size of the lesion itself, you cannot include the margin in your code choice. This means, most likely, that the physician will not receive the full reimbursement he or she deserves. More importantly, complete documentation creates a more precise patient record, which is beneficial for both the patient and the medical practice.
In such cases, coders need to communicate. If the coder must rely on the pathology report for the size of lesion, the measurement will not be as accurate as it would be if taken before the tissue was removed from the blood supply. Physicians may not realize what details a note should contain to correctly code a particular procedure, but often will readily agree to make adjustments once they understand what’s at stake. A little education can go a long way!