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Wiki Excision of lesion

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aaseals32

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Can someone tell me if 11403 is the correct code to use for this procedure and how do I calculate the size? Thanks

Procedure

Excision-Simple Repair:
Location(s): left upper back
Diagnosis/Indication: squamous or basal cell cancer
Pre-op Size: .7cm
Margins taken: .2cm
Excision size: 1cm
Post Surgical Defect Size: 1.5cm

Pathology report

Material submitted:
.DERM, BACK - Skin, Back, Biopsy
Diagnosis:
FOLLICULAR INFUNDIBULAR CYST.NO DYSPLASIA OR MALIGNANCY IDENTIFIED.
Gross description:
.Received in formalin labeled with Erika Left kowitz and 8/2/69, skin lesion of back is a 2.4 x 1.4 x 0.5 cm tan elliptical fragment with a central 0.6 x 0.6 cm pink-tan nodule. The specimen is inked orange, serially sectioned into 8 pieces, and submitted in toto in 3 cassettes, tips in cassette 1. Grossing tech: JLW
 
If your quote under the gross description is stating the patient's name and DOB, PLEASE REMOVE IT IMMEDIATELY!!

You should be using the excision size noted in the procedure note (1 cm) to select your code, not the dimensions noted in a pathology report. The lesion size plus the margin on each side should equal the total excision, which isn't exactly adding up but it is close (.7 + .2 + .2 = 1.1); you might consider querying the provider to confirm the size since it is on the cusp of coding to the next code range.
 
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