calculating excsion size

paula f3

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Hello,
I code for An ASC, we have a plastic surgeon who does quite a few lesion removals. He codes the size from his pathology report , but in his dictated note he lists the size (ie 2.5 cm) , in his dictated notes he does not state margins, now I was taught that if the size is stated without margins , we are to code as stated on the op note, 2.5cm. Please corrrect me if I have misunderstood.
Any and all opinions are most appreciated.
Thank you
Paula
 

mitchellde

True Blue
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If he states the size in the op note then we do take that size, if no margins are noted then we must presume that the size noted includes the margins
 
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