Wiki Can you code a lesion excision based on the incision size?

[ENostrant11]

Can someone tell me if I am wrong? I thought the incision size was only to be used for the repair code (if it is an intermediate or complex repair). I have someone telling me that they have coded a lesion excision as a 11403 based on the following information from an operative note:

"The skin and subcutaneous tissue along the right forearm was infiltrated with 0.5% plain Marcaine. A 3 x 1.5 cm was made along the lesion"

This is the only measurement that is given in the note. How would you code this?

Thanks!
Emily

 

[thomas7331]

You are correct, you need the measurement of the excised diameter of the lesion, including margins, to assign the excision code. You can find this guidance in the CPT book.

I would query the provider if this information was not documented in the record.

 

[ENostrant11]

Thank you, Thomas. Mind if I ask a follow up question?
My providers very rarely include the margin size in their op notes. They do always document the incision size, however. Can I use this measurement as the margins? I've always been confused by this. I know how to code a lesion (greatest lesion diameter + smallest margin size x2) But what do I do when I don't have a margin size, just an incision size?

Example of an excision I am currently trying to code:
Sebaceous cyst along the back measuring 3 x 1 x 1 cm. Incision was 4 x 2 x 2 cm

Thanks!
Emily

 

[thomas7331]

No, the incision size has nothing to do with the margins. Margins are the tissue surrounding the lesion on all sides, which providers will remove when the lesion is known or suspected to be malignant, and this is done in case the cancer cells have spread beyond the visible edges of the lesion. Usually the margins are very small, just a fraction of a cm. Most CPT books have a diagram that illustrates the margins and how to use them to calculate the excised diameter. Your providers may already be including the margin in their measurement. In your example above, the size is 3 cm, and that's all you can use. But a sebaceous cyst would not likely include margins since it's a benign lesion.

Incision length is not really useful information for coding either the excision or the closure because an incision can be either longer or shorter than the actual lesion itself. Per CPT assistant, if the lesion size isn't documented, it's acceptable to use the specimen size that's documented in the pathology report, although that may result in a lower-value excision code since the specimen might have shrunk since the excision was done. The length of the closure can also be different from the length of the incision because it's often necessary to extend the incision to enable the closure to be done correctly, or if portions of the wound are left open to heal on their own. The best practice is if the provider can clearly document both the size of the lesion and the length of the closure that they perform.