excision and revision of scar/wound

lmn

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Im hoping someone can help with this op note.

"An elliptical incision was made around the old scar with its chronic opening. It was deepened through the subcutaneous tissue. the patient appeared to have an old cystic capsule in place. the capsule was excised. Sent to pathology. Wound irrigated. Hemostasis was achieved using electrocautery. the would was closed in deep layers with interrupted 3-0 vicryl sutures. the skin was approximated with 3-0 nylon sutures with vertical mattress technique."

Dr. coded as 11402 and 12032 - The size is not in the op report, but it is in the path as 2 x 2 x 0.3. Any insight would be very helpful.
 

ellzeycoding

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Measurement is taken of the excision size + margins. (widest dimensions) It is not appropriate to base the excision size from the path report because the specimens do shrink in the formalin in the specimen bottle. It must be documented in the record at the time of excision. The original lesion size should be documented as well as the final excision size (including margins), as well as location.

If not in the chart note, then I guess you can go based on path. You said 2x2x0.3 on the path so the widest dimension is 2cm which is appropriate. It could have been larger than 2.0 at the time of removal, so the doc could be shortchanging himself on reimbursement if it were indeed larger before placing in the specimien bottle. (e.g., 11403 is for 2.1 to 3.0cm)

The repair code is based on the length of the repair. The length should be documented as well.
 
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