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Wiki Excision of lesions

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bethh05

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The physician removes seven facial lesions, she dictated the sizes of the lesions as: Midline chin, 5 x4mm
Right chin, 3x2mm
Right upper lip, 2x2mm, etc.
My question is would you add the two measurements to get the size or just use the bigger measurement of the two, since the CPT states the greatest clinical diameter of the apparent lesion.(The physician did not dictate the margins) Any help is greatly appreciated! Thanks
 
Each lesion coded separately

Each lesion is coded separately. If no margins are listed then you can only code the diameter of each one.

Layered or complex closure of surgical wound is separately coded (but you'll need the length of the incision(s) and here you DO add together similar closures in related body areas. Read the CPC guidelines for additional info.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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