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Please Help Asap

  1. Default Please Help Asap
    Medical Coding Books
    I hope someone is able to help me on this I have an op report where the physcian dictates that after general anesth and marcaine he excised: lesion on the right ear; lesion on the penis; lesion on the nipple areolar complex and an abscess in the axilla in total.

    The path report states: Right ear: Chondrodermatitis nodularis hellicis (380.00 the dx code I came up with).

    Penis lesion: Benign squamous papilloma with kollocytosis, consistent with condyloma acuminatum (078.11 versus 222.1?)

    Right axilla lesion: Hidradenitis with multiple follicular infundibular cysts and pericystic fibrosis (705.83)

    Left nipple lesion: Skin tag with architectural features of seborrheic keratosis (701.9?)

    I realize this is a lot to ask but I truly need help. A couple of questions I have is do I use the measurement of the lesion given by the doc or in the path report? Does it shrink in the formalin?

    These are the codes I was told they should be but I guestion them not only because of the size but also the lesion on the penis charge.

    Ear: 11440
    Penis: 54060
    Axilla: 11450
    Nipple: 11200

    The report itself is very short and just states that all four lesions were excised and that they were simple closures.

    Once again thanks to anyone willing to help me out on this as it is greatly appreciated!


  2. #2
    I've always coded by the size of the lesion that the surgeon dictates in the Op note and hopefully he/she gives you the size of any margins as well...I've been told that the specimen does shrink in the formalin. Hope it helps!

  3. #3
    Milwaukee WI
    Default Penis lesion
    Without seeing the actual op note, I would just wonder whether 11420-11426 would be more appropriate vs 54060.

    Definitely code size based on what the physician dictates. Size of lesion includes narrowest margin and is measured BEFORE excision, per CPT guidelines.

    F Tessa Bartels, CPC, CEMC

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