Help with lesion removal please

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Here is the op note:

"On examination, it is a 1 cm, slightly irregular, light tan lesion with a verrucous surface, slightly irregular margins, on the left buttock. It does not appear inflamed or ulcerated or frankly malignant.

After obtaining informed consent under local anesthesia with Betadine prep, the lesion was excised with narrow, free, visible margins. Bleeding was minimal. Hemostasis was achieved using deep sutures of interrupted 3-0 Maxon and then interrupted subcuticular 4-0 Vicryl to close. Steri-Strips completed the closure."

Doc's note: 1 cm lesion, 2 cm wound, 2 layered closure. ***Doctor always notes it as 2 layer closure if there is anything but a skin closure. The above is NOT a layered closure, correct?

The prior coder (who has since been fired) coded this as:
11424 (excise benign lesion, scalp/extremities, 3.1-4.0 cm)
12032 (layered repair, scalp/extremities, 2.6-7.5 cm)

I know this is Coding 101 for a lot of you, but I am looking for some verification. I'm thinking more along the lines of 11402 with no additional closure code.

Can someone help?

Thank you!
 

mitchellde

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You would code the lesion excision to the size of the lesion since he did not give you margins except to say it was a narrow excision, the size of the defect is always bigger. You will need to wait for the path report before you can determine benign or malignant, and with the documentation provided I would not code the closure. If the specimen was not submitted for path then you cannot code this. You must have a path report to report a lesion excision.
 
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You would code the lesion excision to the size of the lesion since he did not give you margins except to say it was a narrow excision, the size of the defect is always bigger. You will need to wait for the path report before you can determine benign or malignant, and with the documentation provided I would not code the closure. If the specimen was not submitted for path then you cannot code this. You must have a path report to report a lesion excision.
The entire lesion including margins was the 2 cm.

The closure is what I was questioning, and this helps me immensely.

If the specimen was not submitted for path then you cannot code this. You must have a path report to report a lesion excision.
I'm not sure what you mean. If I can't code it as a lesion excision, what do I code it as? Do you mean I can't code it as malignant without submitting to path?

Thanks for your help. Greatly appreciated.
 

mitchellde

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You cannot code what you do not know. If an excision was performed then a specimen had to be sent to path, you must hold the claim and wait for the path report before you can submit the claim. You cannot use either benign or malignant excision unless you know. You use the path report to give you the diagnosis as well as the CPT code.
Just because you have a 2cm wound does not mean you have a 2cm excised diameter as the defect is usually bigger than the tissue removed.
 
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"You cannot code what you do not know."

Right, knew that, but...

I worded the other wrong last night.

"Doc's note: 1 cm lesion, 2 cm wound, 2 layered closure."

The lesion plus margins was 1 cm, but the wound was 2 cm, so I have a 2 cm "opening," if you will.

This lesion was not sent to path (as a lot of his are not), "You cannot use either (benign or malignant) excision unless you know," what can I bill it as? I am reading this as I cannot bill EITHER benign or malignant unless path says...there is no code for "unknown" excision, so I have to default to benign....correct?

Ugh...I know what I am trying to say, but I don't think I am conveying it correctly :/

(I appreciate your help.)
 
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mitchellde

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If he did not send for path then he did not perform an excision, a removal of an anomaly that goes deep enough to be classified as an excision must be sent for path. So if he does not send to path then he is not going as deep as the subq layer he is into but not thru the dermal layer, also he is not concerned that this is malignant so where is the medical necessity then? It looks as though he did a shave removal and with out a path report you can code only the 709.9 or it is cosmetic with a V50.x code.
You must send the specimen to path if you are coding for an excision.
so for this one then you would code a shave of a 1cm skin disorder with no repair code.
 
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