Radcoder86
Networker
Doctor excised a lesion and his documentation on the lesion was as follows: 1.6 cm irregular shape, excised in elipse, Defect width 2.1 cm and length 3.2 cm required for closure/flap, closed with 3-0 nylon interrupted sutures, lesion sent for pathology.
I'm not certain on how to code this. He did not note the margins and I'm wondering if it's okay to code off of the defect width, or if that can only be used for the complex closure. Complex Closure includes creation of a limited defect for repair, so I would code a complex closure, correct?
I work for primary care and we don't do a lot of excisions, so I'm uncertain on how exactly these need to be documented. Do the margins plus whether it was full thickness have to be documented, or do the margins already indicate whether full thickness or not?
Help please!
I'm not certain on how to code this. He did not note the margins and I'm wondering if it's okay to code off of the defect width, or if that can only be used for the complex closure. Complex Closure includes creation of a limited defect for repair, so I would code a complex closure, correct?
I work for primary care and we don't do a lot of excisions, so I'm uncertain on how exactly these need to be documented. Do the margins plus whether it was full thickness have to be documented, or do the margins already indicate whether full thickness or not?
Help please!