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New coder needs help with lesions

  1. #1
    Default New coder needs help with lesions
    Medical Coding Books
    procedure: excision of lesion on face.

    Looking at 11440, but would like other opinions.

    Confused on coding lesions. The lesion is benign. The lesion size is 0.5 x 0.5 cm, excised size 1.0 x 0.5 cm.

    If I have for example a pre-excised lesion, do I go with that size to select code. If for example I have a 1 x 2 cm, would I go with the largest size of 2 cm to select code?

    Any help is appreciated. Thank you.

  2. #2
    According to CPT "Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision." In the case for the lesion on the face that is 0.5 X 0.5cm and has an excised diameter of 1.0cm X 0.5cm you add largest diameter (0.5) and the margins of 0.25 on either side of the lesion. 0.5 + 0.5 = 1.0cm. The correct code should be 11441.

    For the second question when a lesion is 1 X 2cm the largest diameter is 2cm. Add the 2cm to the excised margins (which should be in the operative note) to get the appropriate code.

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