Wiki CPt 11400-11600 series


True Blue
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Say you pull documentation on an Excision service. Notice the physician didn't indicate the size of the lesion or margins needed to excise it. And you bring it to the physicians attention the importance of documenting this because it can and will affect how he gets reimbursed on these services.

So in turn, he ask you. Well how do I go about documenting these services.

Can anyone give me a real life example on how you would explain this to the physician. In simple form. Not looking for a text book CPT answer. Looking for coder response to this question. Like on the spot.

Daniel, CPC
Copy the page from CPT

I'd copy the page from CPT that shows the diagram. I do this regularly for my surgeons, even though they already know how to dictate the sizes.

Lesions are measured BEFORE excision ... diameter at the widest point, plus smallest margin reasonable for complete excision.

The length of the excised wound will be LONGER, because they typically use an eliptical incision to allow for closure.

So the doctor should tell you the size of the lesion & margin BEFORE excision
(e.g. patient with benign 2.4cm lesion, including margin), -and-
should dictate the size of the wound if planning to also code for layered or complex closure. (e.g. Resultant wound, 5 cm long, closed by ....)

Hope this helps.

F Tessa Bartels, CPC, CPC-E/M