Excision using post op defect size

Rmn77

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We are having debate in office on documentation & measuring lesions. They do not want to use verbiage of lesion diameter or margins or total excised diameter in the documentation..only what is in the example below:

EXCISION: of Bcc left cheek.
Preop .8 cm by .6cm
Post op defect size 1.0 x .9

What size would you bill?

Some are saying a .8 cm excision based on the largest preop size with no mention of margins. Others want to use post op defect size of 1.0 cm.
Thanks in advance for your response.
 

fwnewbie

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New Haven, IN
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IMO, if the physician is documenting the pre-op and the post-op defect size, the margins are noted. The code would be selected based on the post-op measurement of a diameter of 1.0 (lesion + margin).
 
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