lesion removal documentation


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Medicare requested prepayment documentation for lesion removal. (11642 11422 & 11441) I sent they operative report which showed lesion size in the heading of the op report.

1. Excision of left brow carcinoma in situ (1.5 cm)
2. Left lateral canthus skin lesion excision (0.6 cm)
3. Right oral commissure area skin lesion excision (1 cm)
4. Excision of scalp lesion (2 cm)

They denied stating documentation lacks the margin size of the lesions. I have searched high and low and cannot find anywhere that it states they have to specifically state margin size. Or even specific guidelines on what needs to be in medical record for lesion removal. Can anyone point me in the right direction. It is NGS Medicare Part B.

Thank you in advance.


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Here is the NGS Benign Lesion Removal policy


Generally, when lesions are excised, documentation should include the original lesion size and the final size including margins. Code selection is based on the size of the lesion including margins (greatest diameter). Measurement is taken before the lesion is cut out as the lesion will shrink somewhat after being cut.

From your note, I cannot tell if this is initial lesion size, or excused size (including margins).

Generally in the exam portion of the encounter you will note the initial lesion size.

In the operative note you will include the final excised diameter (including margins) and stating that the dimension note in the chart. Adding the verbiage "including margins" helps.

That being said... I would point out to NGS that it their LCD states that measurement includes margins. If your operative report simply states "Left lateral canthus skin lesion excision (0.6 cm)", then they must assume that dimension INCLUDES margins.

Unfortunately, if that was the initial lesion size (and not the size including margins), you can only code on the smaller dimension and are potentially short-changing yourself on reimbursement.

I can find no requirement that the margins need to be specifically documented... just that measurement is based on lesion+margins.

If defending this in an audit, I would argue that the size documented includes margins.
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