# Lesion type and removal



## JS81coder (Feb 24, 2011)

Being a new coder I could use help determining:

Where in the chart it says what type of lesion this is or how it was removed? Would you use modifier RT? Any advice would be greatly appreciated. 

PREOPERATIVE DIAGNOSIS:
Lesions of the scalp

POSTOPERATIVE DIAGNOSIS:
Same

OPERATION:
Excision of the right posterolateral lesion 6 mm, left hairline lesion 7mm, and anterior midline lesion 6 mm with intermediate defect closure 9mm, 11mm, and 9mm.

DESCRIPTION OF PROCEDURE:
The patient was brought to the procedure room. Using loupe magnification, lesions were all examined with the patient's cooperation and participation. The lesions were then outlined as elliptical excisions and the areas infiltrated with lidocaine-epinephrine solution. The lesions were then excised to the level of subcutaneous tissue. The wounds were then closed by slight undermining the wound edges with re-approximation with 4-0 PDS deep dermal subcutaneous closure and 5-0 Prolene suture.


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## mitchellde (Feb 24, 2011)

you do not code skin lesion with anatomic modifiers Rt, LT or 50, since skin with one organ with no laterality.


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## CoderinJax (Feb 25, 2011)

Your Docs aren't telling you what type of lesions are being removed, other than the site.  This makes a BIG difference.  I see he/she has listed the sizes of the lesions (there are 3 based on the report) as well as the size of the repairs/defects.  Benign excisions are 114XX range and Malignant ones are 116XX range.

*I would recommend you wait until you receive the Pathology report back as that should tell you what was found and will prevent you from filing one way and then having to correct it with the insurance carrier. *

EX: If your Dr. says benign lesion removed, and then the path report comes back stating malignant (SCC, BCC, Melanoma) you have then filed the incorrect code, affecting payment. 

And vice versa if the Dr. states malignant and the path report comes back stating something like dysplastic nevus, then you've filed malignant in error when that is really considered benign. (And the carriers will be wanting their money back, lol!)

**Note: It is very important for your Dr's to also mention the depth they are excising down to. This will tell you whether to choose from the Integumentary section of the CPT book or the Muscoskeletal section. See the CPT Assistant from April, 2010 titled " Integumentary vs Muscoskeletal Lesion Excisions" for details. 

Make sense?


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## mitchellde (Feb 25, 2011)

I am so sorry I did not give a complete answer!  That is what happens when you get distracted and then hit submit.  
What Becky says is true.  What you do know from this note is the lesions were located on the scalp.  and from the descrption of subcutaneous suturing it appears the depth is full thickness, so you should treat it as an excision which means you need to wait for the path for a diagnosis.  Also the path will confirm the thickness.  Also you will then know the excision type.


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## JS81coder (Feb 25, 2011)

Thank you both for your responses. That does help!!


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## sarah.hattel@gmail.com (Feb 28, 2011)

*Benign vs cosmetic lesion*

We have a provider that shave removed a lesion that she felt was b9. In the documentation she stated the lesion was asymptomatic but she was rulilng out a fibrous papule and dermal nevi. "may not be covered under ins" then she quoted how much the lesion removal would be. Cosmetic waiver was signed. Pathology was also charged.

She we have billed this to ins? Or had the patient pay before leaving?

Thank You,
Sarah


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