excision lesion question/clarification

ms123

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We're second guessing ourselves on how to come up with the correct size on a lesion that the surgeon says is 5 cm but on the path it states the specimen measures 7 x 4 x 1.5 cm and the dark, pigmented lesion is 4 x 2 x 1 cm. Could you please explain in detail how you come up with the correct lesion size to apply the correct excision CPT code and the correct intermediate repair code of this example. Hopefully you can clear up this ongoing debate for us. Thank you so much.
 

mitchellde

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just thinking out loud here but it appears he may have stated the lesion size and not the excised diameter, amd since they shrink that would explain the path report difference. So I would say you have 2 choices, either report the size based on the path report of the specimen size knowing the actual was a bit larger, or request the physician amend his note to include the margin size.
 

ms123

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Thanks for the reply! So for the excision code I would use the lesion's actual size (listed within the pathology section - the first number, 4 cm, plus double of the second number (the margins?), as the third number is usually the depth) from the pathology unless I can get the physicians to add on their margins in their dictations. The very latest would make it so much easier!!! And for the repair I would use the pathology total specimen area, 7 cm (first number) plus double of the second number. Is that correct? It gets so confusing when you do this for so long and then someone comes along and completely changes the way you're thinking!
 

mitchellde

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No just the larger number, most lesion have 3 measurments, length, width and depth, so if the physician does not give you either the excised diameter or the lesion size plus margins then the path report is what you have and you use the larger so in yopu eample you have a lesion of 7cm and a repair of 7 cm. Most of the time really it will not make a difference for your codes it really matters when you are at the brink of the next size up or down. You might try showing the physician how he might be missing revenue because he does not accurately capture size. Like I always say when you want to get their attention you kick em in the bucks! Good Luck!!
 
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Lesion measured BEFORE excision

DO not base lesion size on path report when you have a lesion size documented by the physician.

The correct way to document would be: (as an example)
Lesion 5 cm x 2 cm (plus 0.2 cm margin)
Excision wound 7cm x 4 cm

You would then code the lesion size as 5.4cm (5 cm + 0.2cm + 0.2 cm)
And the Repair at 7cm (the longest length)

The specimen shrinks before it gets to pathology, so the pathologist's measurements should not be used if you have any measurements on the surgeon's report.

In this case you have a 5cm lesion (although s/he didn't mention margins) ... so that's the size I would use for coding the lesion.

If you have an excision size on the op note, use the longest measurement for the repair code. If you don't have this, then the most you can use is the 7cm longest measurement of the specimen that path received.

This surgeon is leaving money on the table by not documenting accurately.

F Tessa Bartels, CPC, CEMC
 

mitchellde

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I agree however when the physician does not document the margin size we cannot assume what they were, this could have been a narrow excision with small margins or a wide excision with larger margins we simply do not know. And yes they do shrink so the pth size is not optimal but when it is all you have, he says a 5 cm lesion, the path says a 7cm specimen therefore that is the excised diameter as we know it. The codes are now based on excised diameter not lesion size.
 
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Lesion at widest Plus NARROWEST margin

2009 CPT Professional edition, page 54 or page 55 ... under the guidelines for excision it states: (lesion diameter plus the most narrow margins required equals the excised diameter) (emphasis added by FTB)

Neither the pathologist nor the surgeon mentions the margin. So you can't assume the margin size at all. The largest lesion measurement you have is the 5cm the surgeon documents on the op report, so that's the size of your lesion.

The wound is necessarily much larger ... and the entire specimen is sent in one piece, so your incision length for the repair code, if separately reportable, was 7cm(or whatever the surgeon documented if s/he did on the op report)

F Tessa Bartels, CPC, CEMC
 

mitchellde

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And in my CPT book it states:
However, the size of the specimen can be used when the size of the lesion cannot be located in the operative report or elsewhere in the medical record.
While we are given the lesion we are not given the margins.. the specimen was 7cm so we know at a minimum the margins were 1 cm, so this would appear to be a wide excision.
I still firmly believe the path report is much more accurate than making a guess.
 
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Which version of CPT

mitchellde - which version of CPT are you using?
I'm using 2009 CPT Professional edition and there is no such language in the guidelines for either benign or malignant lesions.

I agree we shouldn't guess. I wouldn't guess that the margins were 1cm. I would only code the lesion itself, since that's the only measurement the surgeon provided.

F Tessa Bartels, CPC, CEMC
 

mitchellde

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2009 professional edition. I guess we just have to disagree on this.. the excised portion is sent to path and they measure it so to me that is as close to the excised diameter as we can get if the physician does not indicate.
 
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