# Help with Lesions Please



## LindaEV (Dec 23, 2010)

Ok,  skin lesion experts...help me resolve some differences of opinion please!

1. Doctor documents "the elliptical excision was 4x2cm" and doesn't specify much more than that...would you code as 4 cm or 6 cm?? ( and yes, I know, Dr should specify...let's pretend he moved to Antarctica where there is no phone service, and this is all we have)
_(my thought...these are the length and width of lesion...I go with largest of 4cm, and thats what the doctor gets since he didnt specify more)
_ 

2. Doctor removes a lesion...it is left open for a flap closure after the path comes back.
Path comes back with positive margins. Doctor does re-excision in two separate segments...an upper portion and lower portion of the margins of the same open wound. 
Code as two lesions or add together???

Thanks!!


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## FTessaBartels (Dec 30, 2010)

*I'll try to explain*

1.  Lesions are measured across the widest diameter PLUS *minimal* margin necessary for complete excision.  The way I read this documentation the physician is reporting the size of the INCISION (not the size of the lesion).  The incision is necessarily LARGER than the lesion itself.   In any case if the lesion were reported as 4cm x 2cm you would code it as 4cm. 

2.  Was this done all in one operative session?  i.e. he excised, waited for path to come back, re-excised and then closed with a flap?  If YES ... the advancement flap INCLUDE removal of the lesion, so you only code the flap.
     If it was TWO sessions. You code the lesion excision based on size of lesion in operation # 1.  Then when he came back to the OR to excise more tissue and complete the flap you code ONLY the advancement flap - and don't forget your modifier for staged procedure!

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## LindaEV (Dec 30, 2010)

Thanks for responding.

I agree completely with you on the first one.

As for #2 I guess I didnt explain very well...sorry about that...the patient has also come back again since the first post...

Visit #1...the patient had the lesion excised on the first visit and it was left "open".

She retunrned on a later date, for visit #2 and had positive margins. The doctor excised a strip from the top and a strip from the bottom of the previous wound *(I think you are saying to code based on ORIGINAL lesion?? So I do not code as two separate lesions? Same wound but it was taken in two "strips" to widen margins)*

She then again, returned on a later date, for visit # 3...one of the margins was still postive (lesion was very close to eye and doc was trying to be conservative...was "clinically negative") Here he took another "strip" and then did graft. (coding graft only)


So...where I *bolded* above...if you dont mind...confirm for me..

THANKS!


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## LindaEV (Jan 5, 2011)

Any more takers?


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## FTessaBartels (Jan 7, 2011)

*Flap vs graft*

Linda,
I think I need to see the three op reports before I can give you an accurate response.  In your first post you mentioned a flap (advancement flap includes the removal of the lesion). In your last post you stated "a graft."  That's a different code.

As always, for unusual cases especially, it is best to post the actual operative note(s) to get an accurate response.

F Tessa Bartels, CPC, CEMC


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