Question excision- benign lesions

hellis88

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Yall, I continue having issues with determining the correct CPT code when the DR does excision procedures for lesions. I know the book says to ADD the greatest clinical diameter plus the margin required for completion, but it's difficult for me to determine what those numbers are from the path report. Can someone shine some light on this for me please? I have included an example path report clipping below.

4516

thanks so much!!
 

thomas7331

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The path report will only tell you the size of the specimen that was received by the lab, which is not always the same as the size that is documented by the provider at the time of the excision. In addition, as is the case here, you can have multiple specimens and it can be unclear if these are separate lesions or a single lesions that was removed in two separate pieces. Whenever possible, you should use the size documented in the operative report (lesion diameter plus margins) or query the provider. If that is not possible and the only thing you have is the path report, and assuming your employer allows you to code from this then all you can do is use the largest single measurement given, which in this case is the 4.9 cm.
 

hellis88

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The path report will only tell you the size of the specimen that was received by the lab, which is not always the same as the size that is documented by the provider at the time of the excision. In addition, as is the case here, you can have multiple specimens and it can be unclear if these are separate lesions or a single lesions that was removed in two separate pieces. Whenever possible, you should use the size documented in the operative report (lesion diameter plus margins) or query the provider. If that is not possible and the only thing you have is the path report, and assuming your employer allows you to code from this then all you can do is use the largest single measurement given, which in this case is the 4.9 cm.
Thank you for your response Thomas! In this case, the Dr. has not completed the OP report yet, but per the brief, he gives "excision and complex closure, back 7 cm". I know to use the 114 codes with the complex repair codes. 4519
 

thomas7331

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I would not recommend coding from a 'brief' description as above. Payers would not accept this as supporting documentation for codes without the full description of the procedure. And in my experience, providers will not always document performing the exact procedure that they list in the title. For example, they might state in the header that it was a complex closure, but the body of the procedure note may only support a layered closure. I would only turn to the pathology report for the sizes as a last resort if the report was completed except for the lesion measurements and there was no way to query the provider for that information. Best to hold off coding until you have all of the information - otherwise you risk submitting a code not supported by the full documentation.
 
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I agree with Thomas. I would wait to code these cases until you have a complete operative report signed by the provider. Our facility has a policy regarding this that basically instructs coders not to code an encounter until all of the documentation has been completed and signed.
 
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