# first stage of a serial excision



## nikkiv1 (Dec 3, 2009)

I'm not sure what code to use for a partial removal of a benign lesion.  The patient had a hairy nevus on her right posterior shoulder measuring 6cm x 3cm.  It had been present for 14 years.  The doctor decided to do a serial excision including two stages of excision to try to give the patient the best chance of scarring.
Here is the op note:

First-stage serial excision of atypical nevus right shoulder with intermediate closure measuring 6.5 x 2 cm

DESCRIPTION OF THE procedure:
An elliptical incision was marked, excising the medial half of the lesion.  The area marked measured approximately 6.5 cm in length by 2.5 cm in width.  This area was then anesthetized with 12 cc of 1% lidocaine with 1:100,000 of epinephrine.  The area was then prepped with Betadine and draped in the usual sterile fashion.  A 15 blade was used to excise the pre-marked ellipse.  The dissection was taken down through full-thickness skin down to the subcutaneous fat.  This was excised and sent to Pathology.  Hemostasis was then achieved.  Undermining was undertaken medially to allow for closure.  This was then done with 3-0 Monocryl used in the subcutaneous and deep dermal tissues in a buried interrupted fashion followed by a running 4-0 Prolene suture in the skin.  The area was washed, and antibiotic ointment was applied.  Sponge, instrument, and needle counts were correct.
How would I code this?  Can I use an excision of benign lesion code even though the entire lesion wasn't removed?
Thanks for any help.

Nikki


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## FTessaBartels (Dec 9, 2009)

*Excision plus repair*

Yes, you can code the excision of benign lesion and the intermediate repair.

BUT ... you need very clear documentation as to the SIZE OF THE LESION REMOVED (not just the size of the eliptical incision, which will be necessarily larger than the lesion removed).

He tells you that the ENTIRE nevus measures 6cm x 3cm ... what part of that was removed?  

His INCISION was 6.5cm x 2cm, which will give you the length for the repair code.

When he goes back to excise the other half of the lesion you MAY need a modifier (if it's within the global period for the first surgery).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## nikkiv1 (Dec 14, 2009)

It does help, thanks!
Nikki


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## mitchellde (Dec 14, 2009)

FTessaBartels said:


> Yes, you can code the excision of benign lesion and the intermediate repair.
> 
> BUT ... you need very clear documentation as to the SIZE OF THE LESION REMOVED (not just the size of the eliptical incision, which will be necessarily larger than the lesion removed).
> 
> ...



Curious, why the dimension of the lesion?, the codes are based on excised diameter. I am just unclear as to where that part fits into the code.  I agree it should be documented, but he gives the size of the excision so that is where the excision code comes from.  I am just a little confused.


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## FTessaBartels (Dec 15, 2009)

*Lesion is measured BEFORE excision*

The size of the lesion is the largest diameter plus *MOST NARROW *margin required. This is as per CPT guidelines.

The size of the incision *may be much larger *for best results in terms of repair.  This is frequently true for plastic surgeons removing lesions as they are hyper concerned about the ultimate results (i.e. scarring).  If you look at the diagram shown in CPT (2009 professional edition, page 54) you'll see that the lesion is 2.0 cm; the minimal margin is 0.2cm, but the actual eliptical incision is MUCH longer (unfortunately CPT doesn't give us dimensions for that). 

Correct documentation for excision of lesions includes *BOTH *the lesion measurement and the length of incision (if you are performing more than simple repair). 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## mitchellde (Dec 16, 2009)

No I understand that but if the margins are not given you cannot assume the size of the margin (you and I have been here before I think, I am having a de ja vue moment!).  The codes state excised diameter.  Just curious as to what you would use for the margins.


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## FTessaBartels (Dec 18, 2009)

*Go back to physician*



mitchellde said:


> No I understand that but if the margins are not given you cannot assume the size of the margin (you and I have been here before I think, I am having a de ja vue moment!).  The codes state excised diameter.  Just curious as to what you would use for the margins.



Exactly - no assumptions. I would go back to the physician and ask for the size of the lesion including the most narrow margin required. 

The ASPS (American Society of Plastic Surgeons) specifically states in their coding seminars that lesion exision documentation must include BOTH measurements - the lesion, including the most narrow margin; and the incision (if more than simple repair is being done).

F Tessa Bartels, CPC, CEMC


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## artemissp (Dec 7, 2010)

*Plastice skin closure*

I have "plastic closure" as one of the Procedures performed in a medical report i am coding but i cant find a code, does it exist?


Thanks,
Artemiss


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