Wiki Excision Size vs Lesion size vs path report

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AR2728

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My surgeon documents lesion measured 1.8 cm in widest dimension, and that he made a 3 cm elliptical excision. He does not include documentation for the smallest margin size or clarify that the 3cm includes the smallest size margins. I know an elliptical excision could include the the size for the largest margins, but do not have further information regarding this. The path report then states 1.9 x .9 with centrally located 1 cm lesion.

Would you code this to the 3cm elliptical excision or the 1.8 acutal lesion size? I have a hard time jumping to the 3 cm code when I know there is a possibility that this includes the larger margin sizes. Do you take into account the path report size at all in this case?
 
Thank you. I've been doing that thus far, but having one of those moments where I question myself. It's so nice to get advice from others!:)
 
Coding Lesion Excisions when no size is documented by physician

I have always been told that when there is not a size documented, to default to the smallest size listed in CPT. However, I cannot find this is writing anywhere. Please help!
 
I heard the Same thing when i worked for a Large Derm Group. It was rare when we applied that rule. If you think about it the Doc (IMO) Couldnt go back and Addendum and say "5.0cm Lesion was excised" weeks Later.
 
In the original post the excision size was documented, the codes are based on excised diameter , this is stated on the CPT book. If the provider does not document a size at all then it is best to return the documentation for specificity. However it has been accepted CUSTOM to use the code for the smallest size.
 
Do not use the size of the elliptical excision

You would code this as 1.8 cm - You do not code this as the 3 cm elliptical. The codes are for the lesion plus margins. An elliptical excision is not about margins but about appropriate closure technics. Please see the pictures associated with the excision codes in your CPT. It shows an elliptical excision and states to use the lesion plus margins and not the widest point of the elliptical excision. If you aren't given the margins then you can only use the lesion size...do not assume a margin size.
 
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