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Skin Excision

  1. Question Skin Excision
    Medical Coding Books
    I need some clarification on how to code for skin excision.
    Documented in the note is 1cm lesion on the back that was excised and sent out for biopsy.
    Do I select the CPT code based on what is documented in the note or do I wait on the pathology report to get those measurement to choose the CPT code which was 1.5 by 1.2 by 0.6 (3.3cm). Cpt code 11401 or 11404.

  2. #2
    Columbia, MO
    you code for the largest documented diameter, this is not a 3.3cm lesion it is a 1.5cm lesion. The specimen will have shrunk by the time the pathologist measures it so we always go by the largest documented diameter in the note, if he tells you what the margins are then add that in but if he just gives you excision size then use the largest measurement given.

    Debra A. Mitchell, MSPH, CPC-H

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