Internal Medicine Coding Alert

Published on Sun May 09, 2010 PDF

The success of your lesion excision coding relies on right timing, accurate reading.

If you want to make sure you've got the most accurate CPT and diagnosis code for lesion excision, wait until the lab sends you its report before finalizing your billing. Sometimes, holding off that claim might prove to be the smartest thing you'd have to do.

Try Your Hand at These 3 Scenarios

Scenario 1: Your internist removes a 2-mm suspicious skin lesion from a patient's back using a 1-mm margin. What choice of codes do you have?

Scenario 2: You read your internist's documentation as follows: "I removed one approximately 9-mm lesion from the patient's wrist using surgical curettage. Lesion had a red outer crust and an irregular border, but it looked dissimilar from the patient's actinic keratosis spots on her face, so I am uncertain of the lesion's status. Sent lesion to the lab and will await results." What ICD-9 should you report?

Scenario 3: The internist excises an irregularly shaped, malignant lesion -- as the pathology report later determines -- from just below the patient's right shoulder. The lesion measures 2 cm at its widest point. The physician allows a margin of at least 1.5 cm on all sides to remove all malignant tissues. What should you report?

Ready for the test? Turn to page 45 for answers.