# Clarification for lesion sizes



## bethh05 (Mar 2, 2010)

I have been reading over the forums archives in search of some answers. The physicians here are not very good at dictating sizes and margins, so I am kinda forced to use the path report. I have been told that the first two measurements on the path report are the lesion size, but I have also read that you should go by the biggest measurement on the path since margins are not dictated.  

Example the path reads: The specimen consists of an unoriented skin ellipse measuring 2.8x1.5x0.7. Would you code 2.8 as the lesion size or is 2.8 and the 1.5 (being the margins) the size? If someone can give me some insight I would REALLY be thankful.


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## FTessaBartels (Mar 3, 2010)

*Coding for the surgeon*

First - I am coding for the surgeon ONLY.  

What I tell the surgeon(s) is that if there is NO lesion size dictated, we will default to the smallest size.  Ditto if there is no length of excision/repair dictated we default to the smallest size (or the size of the lesion, whichever is larger).

Of course, since I am coding for the surgeons there is an incentive for them to specify the sizes. (Otherwise they are leaving money "on the table.")

Regardless, though ... if surgeon dictated a lesion measuring 2.8 x 1.5 I would take the largest size as my diameter ... that's what CPT tells us to do. 

Hope that was helpful to you.

F Tessa Bartels, CPC, CEMC


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## codedog (Mar 4, 2010)

Good question to ask bethh05

 I seem to have that problem to at  the  ASC  where I work at . We get the booking   that is a different code  - lets say here is an example 

booking comes across as back mass cpt code 21930 is the code they used to schedule it 
operative report stated  its just a simple cyst excision-706.2dx  which is the 1140x  series -no size is in operative report, now  I GET PATH REPORT AND i go by the largest size, and I  code it then . Now on the doctor side , they have an outsource biling company, they coded as 11400, the lowest size, because no size is on operative report and they only code from operative report to my understanding. 

Now first the doctor is thinking they are using 21930 , which they are not, 
BUT ANYWAY NOW IN 2010  excisions codes  are in musculoskeletal  system by size anyway

Now to finish this soap opera story , I tell doctors all the time to please dictate size, please, and I still have  those few doctors  that wont or forget to do it. 
ANY suggestions on how to tell them ?


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## bethh05 (Mar 4, 2010)

I wish I had a good answer for you, when I have queried the physician's offices, I get please see the path report. Sometimes they will dictate the size in the H&P's.


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## BFAITHFUL (Mar 10, 2010)

You know that is the way I used to think Ftessa.... but I have been given helpful information including from CPT,   Because the lesions could be fusiform wedge excisions & even elliptical , these excisions are much wider than usual, it's like looking at the shape of an eye, very wide and then thins out at edges, this is done so as to minimize scarring, & other reasons so a much larger excision is done, and if the lesion size plus the width of the narrowest margins is not clearly indicated , what you can be doing is overcoding by using the size on the path. report ( see some examples below)


The Coding Institute 2008 Vol. 11 No. 5

QUESTION:      excision of lesion sample op report:      patient taken to operating room patient had two converging semi elliptical incisions were created in the subcutaneous tissue.  the encompassing skin wedge and soft tissue mass were meticulously dissected free with blunt and sharp scissors.  it was noted to go into the fat tissue, it was a hard fibrotic mass.  we further explored the area no other suspicious appearing lession was noted.  the wound was flushed copiously we the closed the wound.  
Path report:  received is an elliptical portion of tan tissue measuring 2.6cm x 9 x 1.2cm, a centrally placed ulcerated lesion measures 3 x 3mm.  no orientation identified.  the surgical margins are inked.  
RESPONSE:  Choosing a CPT code from this report won't be simple.  the provider has the responsibility to measure the lesion with margins prior to excision of the lesion,  lesions shrink when the pathologist analyzes them, which means the 3mm x 3mm in the sample path report is probably smaller than the lesions actual size, but if the surgeon can't provide the actual measurements, you may have to code this excision conservatively by using the 3mm x 3mm lesion measurement because you have no documentation of the narrowest required margin or size of lesion.

Another example:

"Note that the "excised diameter" does not represent the dimensions of the total fusiform excision, which is 5 by 1.1cm.  Coding is determined by the excised diameter definition.  If this is confusing consider how this lesion would be excised if the defect was to be reconstructed with a skin graft.  The excision would measure 2.1 by 1.1 cm ie, the amount of tissue resection to adequately excise the lesion (not the 5 by 1.1cm fusiform excision)  This is where the definition of excised diameter should make sense.

CPT ASSISTANT:  This is where the two sample diagrams from the CPT book comes into play  (diagrams attached)

CPT code selection is based on the size of the
lesion prior to excision, including surgical
margin, recorded in centimeters (cm)

Code selection is determined by measuring the
greatest clinical diameter of the apparent lesion plus
that margin required for complete excision (lesion
diameter plus the most narrow margins required equals
the excised diameter).
4. The margins refer to the most narrow margin required
to adequately excise the lesion, based on the
physician's judgment.
5. The measurement of lesion plus margin is made prior
to excision.

AMA 2008 Professional Edition, page 53-54
How coding from Pathology Reports lead to
*Lesion Measurement Overpayment*
Lesion Size…
Size of Lesion Size of Specimen
The specimen size is much larger than the actual lesion size. If the specimen size is the only recording on the pathology report and
the CPT code is selected from the pathology report, then an up-coded CPT is billed to the payer resulting in an overpayment.
                                   OR
*How coding from Pathology Reports lead to
Lesion Measurement Underpayment*
Size of Lesion Size of Specimen
The specimen size can be the lesion size. The specimen size recorded on the pathology report is likely to contain a less accurate measurement,
due to the shrinking of the specimen or to the fact that the specimen may be fragmented, resulting in undercoding and underpayment.


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## FTessaBartels (Mar 11, 2010)

*To clarify*

If NO size of lesion noted: We code to the smalled size in CPT.

If NO size of INCISION noted (when layered closure used): we code to the size of the lesion (if specified) OR to the smallest size of repair - whichever of *these two *is larger.

So if physician states: Excision of benign lesion, right forearm,  1 x 2 cm with layered closure.   You have 11402 for the excision (no margins are specified, so I can only use 2 cm as my largest diameter). And 12031 for the repair (even though length of the eliptical incision was most likely longer than 2.5 cm - if the surgeon didn't specify the length of the incision we have to go with the smallest size.)

Hope that is more clear.

F Tessa Bartels, CPC, CEMC


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## BFAITHFUL (Mar 11, 2010)

Yes, but if it's a fusiform wedge & ellipitical excisions, you cannot use the excision size either as you mentioned above, as stated in the example below



"Note that the "excised diameter" *does not represent the dimensions of the total fusiform excision, which is 5 by 1.1cm*. Coding is determined by the excised diameter definition. If this is confusing consider how this lesion would be excised if the defect was to be reconstructed with a skin graft. The excision would measure 2.1 by 1.1 cm ie, the amount of tissue resection to adequately excise the lesion (*not the 5 by 1.1cm fusiform excision*) This is where the definition of excised diameter should make sense.

Believe me, this also was driving me crazy, until I sent question to AMA for clarificiation, among other consulting services.    excised diameter is not based on the size of excision.


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## BFAITHFUL (Mar 11, 2010)

Here's another article from SurgiStrategies


Be careful not to confuse the length of the incision with the width of the margins. Often, for instance, the physician will make an incision that is longer than the lesion to “flatten” the resulting scar, but this has no bearing on code selection. Base your measurements on the actual size of the lesion before the surgeon performs the excision and prior to sending it to pathology, not according to the size of the surgical wound left behind

After the lesion has been closely examined, the area will be cleaned with some very strong anti-bacterial agents to lower the likelihood of infection. After this, the area will be surrounded by a surgical drape to highlight the area and give the doctor a sterile (germ-free) zone to work in. 

Next, the doctor will sometimes draw an outline, along which they plan to cut with a scalpel to remove the lesion. The usual shape looks like a cat's eye. (fusiform wedge excision)


(there's actually a diagram that was inserted here, you must go to site to see it, http://www.virtualmedicalcentre.com/treatments.asp?sid=81


This shape is the best because it allows for better healing and makes stitching it up afterwards far easier. The size of the area can vary, but usually it is about three or four times as long as it is wide. 

The alignment of this cut is important; the doctor wants there to be as little stress on the wound as possible to decrease the chances of it being painful or even breaking apart. To do this, it is lined up along where the skin is under the least tension. The doctor can tell this by looking at the folds and creases in the skin.


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## BFAITHFUL (Mar 11, 2010)

i dont know why it cut the website off, its supposed to be

http://www.virtualmedicalcentre.com/treatments.asp?sid=81


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## BFAITHFUL (Mar 11, 2010)

okay dont know why its cutting off, the word after .com is treatments


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## cconroy (Oct 14, 2011)

I am an outpatient surgery coder for a hospital. For years our policy for coding excisions when there were no margins or sizes dictated was to defer to largest number on the path, this being the largest diameter plus margins. We have been taken over and the new policy is to multiply the lenghth x width that is dictated on the path to arrive at the sq centimeter of the excised lesion and this number would determine the cpt code used. When I showed them the article from The Coding Edge of May 2009 explaining how to arrive at a lesion size based on the Path report I was told that that information was only for phycision office coding only. Any advice on this would be appreciated.


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