tci General Surgery Coding Alert - 2015 Issue 12

You Be the Coder: Earn $139 With Accurate Lesion Measure

Question: One of our surgeons reports malignant lesion excision by stating the dimension of the excised tissue, not the lesion itself. For instance, the surgeon documented an “excised diameter” of 11 cm by 3.1 cm for a melanoma on the patient’s left leg. How should we code this? SuperCoder Subscriber Answer: Without talking to the surgeon, the best code you can choose for this case is 11604 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm). However, you might be under- or over-billing because the surgeon’s documentation...

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