First - I am coding for the surgeon ONLY.
What I tell the surgeon(s) is that if there is NO lesion size dictated, we will default to the smallest size. Ditto if there is no length of excision/repair dictated we default to the smallest size (or the size of the lesion, whichever is larger).
Of course, since I am coding for the surgeons there is an incentive for them to specify the sizes. (Otherwise they are leaving money "on the table.")
Regardless, though ... if surgeon dictated a lesion measuring 2.8 x 1.5 I would take the largest size as my diameter ... that's what CPT tells us to do.
Hope that was helpful to you.
F Tessa Bartels, CPC, CEMC
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