READER QUESTIONS:
Encourage Your Surgeon to Document Lesion Size
Published on Tue Sep 01, 2009
Question: When a physician states that the lesion/cyst/mass excised from the skin or subcutaneous tissue was 3 x 3 x 2 cm, how do you choose the size for coding? The surgeon didn't break out the size of the lesion or the margin. He only states the dimensions. Would I code this as a 3 cm, 5 cm, or 8 cm excision? Michigan Subscriber Answer: In this case, you can bill only for the 3 cm lesion excision, based on location and malignancy, since your physician did not provide sufficient documentation to code any other code. For example, if the surgeon removed a benign lesion from the patient's upper arm, you would report 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm). How it works: The size of the lesion for coding purposes is the largest diameter [...]
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