Cpt code size based on pathology report for lesions

pwright3603

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We are having a debate on whether we as coders can choose a CPT code if the Dr did not or cannot state the size in the operative report. I know that is not approriate to code by the pathology report alone but if that is all there is (ie. a retroactive audit), then is it correct to use the path report OR use the smallest size in the code set (11401-11406).

If it is approriate to use smallest CPT code, please direct me toward the written guidlines.

thanks!:)
 

mitchellde

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We always used the size for the specimen from the path report if it was not stated by the provider in the op note, it was never an issue on audit.
 

pwright3603

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Debra, thanks for your fast response, that is what I have done as well. I am getting feedback from others that they use the smallest size in the code range. I have lots of documentation that says NOT to use the path report, that we are supposed to query the physician, but if that is not possible there is no documentation that we ARE supposed to use smallest size in the code range. I prefer getting it in writing, don't you?
 

mitchellde

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I agree but I have never come across an official source that states you are not allowed to use the size given in the path report. You might check the CPT assistants it seems to me they had something on this topic years back.
 

pwright3603

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Debra, I agree 100% with you. I do not have CPT Assistant back to a reference of August 2000 page 5. I found a web page that referenced that issue, but still did not answer THE question. thanks again!
 

landryi

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CPT Assistant does comment on coding the size but leaves it a bit gray as they do not come out and say "You must not" but more like "we frown upon" the coding the size from the path report. See below...

CPT® Assistant Detail
Article Detail
*
Year: 2000
Issue: August
Pages: 5
Title: Review of the Integumentary Excision of Lesion Codes (11400-11646)
Body: Coding Communication

The Removal of a Lesion
To properly code an excision of a lesion, the physician must document the size and location of the lesion. The size of a lesion is measured by its clinical diameter for a circular or elliptical lesion. The diameter is the length of a straight line segment that passes through the center of a figure, especially of a circle or sphere, and terminates at the periphery. If the lesion is asymmetrical or irregular, the maximum width is used to measure the lesion. The physician should make an accurate measurement of the lesion at the time of the excision, and the size of the lesion should be documented in the operative report. A pathology report is less likely to contain an accurate measurement due to the shrinkage or fragmentation of the specimen. When coding the removal of a lesion, do not report the size of the surgical defect created or the affected area.
 

pallard

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Hi Deborah, do you have any authoritative guidance that says it is okay to select the smallest size lesion when the provider does not document a lesion size?
 
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mjt

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Coding lesions

I found in HCPRO just coding article from May 27th, 2011 EXCISE TUMOR CODING CONCERNS. it does state that when a physician doesn't document the size of the tumor, coders must code the smallest size. Auditors won't look at the pathology report. they will knock you down to the smallest size.


Michele Turocy, CPC, CCS
 

teresabug

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per AMA and the AAPC, the lesion size is to be measured along with margins before the excision. Skin/tissue "shrinks" so measuring a lesion size from the path report is inaccurate.
 

teresabug

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per AMA and the AAPC, the lesion size is to be measured along with margins before the excision. Skin/tissue "shrinks" so measuring a lesion size from the path report is inaccurate.
 
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