Question Lipoma Size in PostOp Diagnosis

SALAZAS

New
Messages
3
Best answers
0
Hello,
I’m getting mixed information. If provider documented the size of the lipoma in his/her Op Report in the PostOp Diagnosis info area, is this sufficient to code the correct Lipoma excision or does the physician has to document the size within the body of his/her Op Report too?

example:
Pre Op Diagnosis: 6cm right upper thigh Lipoma

Procedure Detail: location on Right thigh excision of lipoma through subcutaneous tissue.

“Dr has more info for procedure, this is just an example that he/she did not indicate the size within his procedure” can I still code the CPT greater than 3cm or do I have to tell the Dr to put the measurement within the procedure info?

thank you
 
Top