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How do I code a shave removal lesion when size is not documented.

pallard

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Winston Salem, NC
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Physician does a shave removal of a lesion on the arm but he/she failed to document the size and it is not included in the path report. Is it correct coding to assign a code that reflects the smallest size lesion, which in this case would be 11300 for a lesion 0.5 cm or less? Please refer me to the coding guidelines.

Thank you!
 

btadlock1

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Lubbock, TX
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Physician does a shave removal of a lesion on the arm but he/she failed to document the size and it is not included in the path report. Is it correct coding to assign a code that reflects the smallest size lesion, which in this case would be 11300 for a lesion 0.5 cm or less? Please refer me to the coding guidelines.

Thank you!
Easy answer: You don't code it. Ask the provider to make an addendum - their documentation is insufficient, to meet the description of any of the shave codes, without the diameter of the lesion being documented.
 

CFisher5

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North East, MD
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Technically, you could bill for the size of the lesion which is usually not the size of the actual removal. This would only be acceptable if a phrase such as "entire lesion was removed" is used. However, I agree with the others. I would send it back to the docotor to make an addendum to the note for the size of the lesion AND the size of the removal. You also want to make sure that the information gets put onto the path report. You should stress to your doctors that they MUST document the lesion size and the removal size even if it is a shave. Or, you should notify a supervisor that the documentation is not being completed properly.
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