Otolaryngology Coding Alert

Question: I have been cross-referencing the size of excised lesions noted in the op report with the size noted in the pathology report and am confused that they are often different sizes. Which measurement should I use for coding? New York SubscriberAnswer: You should always choose a code based on the size in the physician's documentation, not the size documented in the pathology report. One reason not to code from the pathology report is the specimen generally will shrink in formalin, sometimes to half its original size, which would mean you under-code and cost your otolaryngologist deserved reimbursement.On the other hand, coding elliptical excisions from the pathology report can cause you to make the opposite mistake: over-coding. Because of the elliptical shape, the size documented in the pathology report might be the specimen size, not the lesion size, and therefore might be a lot larger than the actual lesion and [...]