tci General Surgery Coding Alert - 2009 Issue 13

READER QUESTIONS: Encourage Your Surgeon to Document Lesion Size

Question: When a physician states that the lesion/cyst/mass excised from the skin or subcutaneous tissue was 3 x 3 x 2 cm, how do you choose the size for coding? The surgeon didn't break out the size of the lesion or the margin. He only states the dimensions. Would I code this as a 3 cm, 5 cm, or 8 cm excision? Michigan Subscriber Answer: In this case, you can bill only for the 3 cm lesion excision, based on location and malignancy, since your physician did not provide sufficient documentation to code any other code. For example, if...

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