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lesion excision help

  1. Default lesion excision help
    Medical Coding Books
    I have an op report stating wide excision of malignant melanoma of right breast 1.5cm x 1.5cm, the report says " patient had a circular incision made directly around entire lesion, which resulted in a 1.5cm defect and a 1.5cm defect superiorly and inferiorly in oblique manner"

    Would you take this to mean that the margins were 1.5cm all around. I want to just use the 1.5cm measuremenat since he doesn't specifically mention margins???

  2. #2
    When I have these situations come up I will go speak with the provider about their documentation and ask if those were the margins, and if not, ask your provider to dictate an addendum to the original note, stating the margins to help you code it correctly and get them the best possible reimbursement the work performed.
    Robin Plowman, LPN, CPC, CPMA, CEMC Analyst Manager ~Crazy Coder!! ~

  3. #3
    Columbia, MO
    This doctor is giveing you the entire excision size which is inclusive of the margins so you go with 1.5 cm. I have had a ton of doctors state their excisions this way.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default

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