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Wiki What size do I go by?

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KaylaRieken

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Waukee, IA
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My doctor documented he excised a 7-9 mm lesion. In the op note he states that he marked out an elliptical lengthwise incision around the lesion approximately 2 cm in length and 1 cm wide. What size do I go by?
 
You measure the length of the lesion, plus the margins on each end. When he says he "marked out an elliptical lengthwise incision around the lesion approximately 2 cm in length," does he mean he made a 2 cm margin? If so, then 7 (or 9?) + 2 + 2 = 11.
 
Verify with pathology report

I've had the issue on multiple occasions where the physician is not precisely measuring (or at least not documenting the measurement) on the op note. I verify with the pathology report, which always states the exact size.
I typically await the pathology report anyway to determine if benign or malignant.
 
Yes, I bill based on the largest dimension of the pathology report. ie 1.2cm x 0.8cm x 0.2cm is billed as 1.2cm size.
 
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