tci General Surgery Coding Alert - 2007 Issue 10

ICD-9 Lesion Coding: Why Patience Pays

The info you need is in the pathology report, not necessarily encounter notes When assigning a diagnosis for lesion removal, remember that you should wait and rely on the pathology report to choose the correct ICD-9, rather than refer to the surgeon's own note. Consider this example of why this is important:The procedure: Your surgeon documents, -I removed one approximately 9-mm lesion from the patient's wrist using surgical curettage. Lesion had a red outer crust and an irregular border, but it looked dissimilar from the patient's actinic keratosis spots on her face, so I am uncertain of the lesion's...

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