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  1. #1
    Default Lesions
    Medical Coding Books
    I'm hoping someone can help me. I rarely code lesions and especially not multiple ones. My patient is in a nursing home but my doc did all procedures as an outpatient at the hospital. I have come up with what I think is correct but I want to double check. I have enclosed a portion of the note. Thanks

    Procedure: Multiple elliptical excisional biopsies and punch biopsies for suspected basal call carcinoma.

    ....In the right maxillary area, there was a 1.5cm ellitical excisional biopsy done and closed with 5-0 nylon interupted suture. On neck on the right side, there were two elliptical biopsies, one approximately 3cm and one 2 cm in lenghth through skin and superficial fat and closed with 4-0 nylon interupted sutures. On the right chest, there were two 5-mm punch biopsies done and closed with one 5-0 nylon suture for each and on the right chest there was a large 4-cm elliptcal excision done. There was undermining of the margins in order to close the lesion. This was closed with six 4-0 vertical matress sutures and four interupted simple sutures. (he used basal cell carcinoma dx for all lesions)

  2. #2
    Milwaukee WI
    Default Lesions are coded separately
    Read the guidelines in CPT for Biopsy of skin (CPT 11100-11101) and Excision of Benign (CPT 11400-11446) and Malignant (CPT 11600-11646) Lesions.

    Each lesion excision or biopsy is coded separately, defined by location and size. Your physician calls these all "biopsies" but if he actually excised the entire lesion, even using a punch biopsy technique, then it should be coded as an excision not a biopsy. You may have to query him to verify.

    You will need to have the pathology report before you can choose the correct codes. "Suspected" basal cell carcinoma is NOT a definitive diagnosis. Never give a patient a cancerous diagnosis without the confirmation of a pathology report.

    Simple closure is included in all these codes. I see that the excision for one lesion required undermiing and layered closure. This closure is separately reportable.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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