Wiki Excision of lesions

[nc_coder]

The physician performs an excision of lesion. On the procedure note it states "excision of lesion". The site and size of the lesion was recorded in a previous progress note when the lesion was examined but not on the note for the date of the procedure.
This data actually needs to be documented on the procedure note too, right?

Please advise. And include points of reference if you can.
Thank you.

 

[Texascoder64]

The excised diameter including the margins are measured at the time of the full thickness excision (for cpts 114xx or 116xx) that is how you select the correct size of the lesion excision. Furthermore, if you perform an intermediate 12xxx or complex repair 13xxx, your code selection on the repair is the final wound defect length.

If the Dr. selects the cpt based on the size of lesion before excision -Dr. can be missing out on a larger cm code in most cases.

 

[valleycoder]

Great job for seeking advice on this as it absolutely does need to be included on the procedure note. If the provider is ever involved with a payer audit, the records reviewed are records for the date of service audited. They will not review records of another date of service to seek measurements. If the measurement is missing on the procedure note, it could possibly be downcoded by the auditor to the lowest level of excision, which could be a big reduction in payment. I would definitely recommend tightening up on this.