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Size of Lesion, Lipoma & ect. on Operative report

  1. Default Size of Lesion, Lipoma & ect. on Operative report
    Medical Coding Books
    Does the size of lesions, lipomas ect. have to be on operative report or can it just be included somewhere in the patients chart? I appreciate any information.

    Thanks,
    Vickie

  2. #2
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    I personally go by the path report because you usually have pathology sent when removing a lipoma, lesion etc... the op report can specify also, but the path is more accurate.

  3. Default
    I appreciate the info.

    Vickie

  4. #4
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    I really think the OP or H&P would be the most accurate regarding size. The lesion will be small on pathology due to the use of formaldehyde or other fixatives.

    Charla

  5. #5
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    I agree with Charla and use the pathology report sizes as a last resort.
    Mary, CPC, CANPC, COSC

  6. #6
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    I have always been taught to use the pathology report when either the op report says mm or doesn't say at all. So now I am confused. Do you wait to hear from the Dr. with your query (usually a week) or do you use your path report that you have the next day?

  7. #7
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    If you have mm it can be converted to cm. The optimal way of coding would be from the op report and pathology as a last resort. As Charla pointed out, tissue has a tendency to shrink when placed in formalin.

  8. #8
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    rather than waiting for the doc, check the H & P that was done for surgery, if its not there I would call his office and ask his coder or assistant to check the chart to see if it was documented there and ask them to fax to you to put in the ASC chart as a CYA. If its not there either, then you can wait a week for the doc to prevent leaving money on the table or as a last resort use the pathology report and take the lesser revenue.

    As of Jan 1....excision of lesions are going to be a MAJOR ORDEAL for everyone!!!
    Mary, CPC, CANPC, COSC

  9. #9
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    Ok what did I miss about 2010 lesion codes. Not to sound unprepared but I don't want to get it wrong.


  10. Default
    Well, for one thing, excision of subcutaneous/subfascial tumors will require dimensions as of Jan 1, 2010 and there are resequencing issues related to these codes, too. Take a look at 25065 through 25078.

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