Wiki How would you code this?

[jhanmer83]

Hey Everybody!
I'm trying to get opinions on how to code this procedure. We're having differing opinions between coders here at the hospital and I want to find out what everyone else does, or what you were taught to do when the provider doesn't measure or specify the size of the lesion removed. Personally, I was taught to default to the smallest lesion if it's not specified in the note. If this is how you were taught, can you provide any links to information on this?

"She had an anterior and posterior repair several months ago and has had a lot of trouble having intercourse since then. Just not having enough room. Have given her dilators. She is able to handle a medium dilator but she said the large dilator hurts and does not seem to really stretch the tissues.

On exam today the patient's point of maximum tenderness is along the scarred area at the posterior repair about a centimeter to 2 cm within the introitus near the area of the hymeneal ring. I believe that with intercourse this area skating stretched and pushed on and it really seems to be where she hurts the most. This area was cleansed with Betadine and injected with 1-2 mL of 1% Xylocaine I made an incision through the middle of that scar and use iris scissors to excise a portion of that scar. Hemostasis obtained with pressure and a little bit of Monsel's. With the lidocaine and lidocaine jelly that I applying she had no pain from this area felt much softer when I was done."

Thanks in advance!

 

[Anastasia]

Use 12001 for scar revision

 

[csperoni]

I do not agree. If this is scar revision, I was always instructed to use the COMPLEX repair codes for scar revision. Per supercoder:
Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.

I would code this 13131 unless you can get clarification in documentation of the size being larger than 2.5cm.
For removal of lesions, if the notes don't specify, I will refer to the pathology which will give the exact size. Similarly, I await the pathology to determine if I should be using the benign lesion codes or malignant lesion codes.