Reader Question: Use Surgeon's Lesion Measurement for Size

Why This Topic Matters

Accurate lesion size documentation can affect CPT code selection and reimbursement, and the article highlights the difference between operative measurement and specimen measurement. It is useful for avoiding undercoding when relying only on pathology documentation and for understanding how final diagnosis information supports code choice.

Article Sections

1. Question

   Introduces a reader scenario involving multiple skin lesions and a question about selecting the appropriate excision code after pathology results are received.

2. Answer

   Summarizes the relationship between the surgeon’s operative documentation and the pathology report for lesion excision reporting, including the role of specimen handling and measurement.

3. The impact

   Describes the reimbursement and documentation implications that can result when the original operative size is not documented.

4. Example

   Provides a documentation-based scenario illustrating how excision size and pathology findings can affect CPT code selection and payment.

5. Important

   Clarifies the general role of pathology results in supporting benign or malignant excision code selection.