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Excisional biopsy of mole on leg

  1. #1
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    NEW ORLEANS
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    Default Excisional biopsy of mole on leg
    Medical Coding Books
    An illiptical incision was made on left lower leg to encompass excising the mole with grossly negative margins. Electroocautery was used to disect the skin and mole from the subcutaneous tissue. The specimen was marked for orientation. Hemostasis was achieved with electrocautery. The skin was closed with 4 nylon mattress and simple sutures. a sterile dressing was applied. Path report came back as an elliptical fragment of skin which s 2.7x0.8 x 0.6 cm with dx code 709.0
    Would cpt code
    11403 with 709.0 dx or should I code it into musculoskeletal system?

  2. #2
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    Quote Originally Posted by trent123 View Post
    An illiptical incision was made on left lower leg to encompass excising the mole with grossly negative margins. Electroocautery was used to disect the skin and mole from the subcutaneous tissue. The specimen was marked for orientation. Hemostasis was achieved with electrocautery. The skin was closed with 4 nylon mattress and simple sutures. a sterile dressing was applied. Path report came back as an elliptical fragment of skin which s 2.7x0.8 x 0.6 cm with dx code 709.0
    Would cpt code
    11403 with 709.0 dx or should I code it into musculoskeletal system?
    Other than the fact that your dx code needs a fifth digit, if that is what the path came back as then you are good with dx. As far as the procedure, other than the path, is there any indication of size in the operative report? If nothing is in the operative report then you are left with 11400 only. You may NOT use te path report to obtain the size of the lesion excised if it is not documented in the operative report.
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer
    susanwardcpc@live.com

    A small act of kindness a day can make someone's day special

  3. #3
    Location
    NEW ORLEANS
    Posts
    956
    Default
    I thought you could use what was on path report if it was not in operative report. I trust your judgement, but these doctors hardly ever put the size on operative report , can you link me to a web site that has this policy, for I can show them , maybe they will place the size more if I show them this and how much money they are losing not doing so. Thanks

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