Dermatology Coding Alert

Question: Apatient had a squamous cell carcinoma of the nose removed in our office. The surgeon did not document the size of the lesion anywhere. Multiple frozen sections were done of the same lesion. Can I add up the sizes of the pieces of tissue from the pathology report to get the total size of the lesion for coding purposes?

Georgia Subscriber

Answer: You cannot use the pathology report to code according to lesion size because you must include the margins in the total size. In this case, when documentation is not available, you should report the smallest code applicable for the appropriate body area. For instance, in this case, report 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less). The pathology report should justify the excision.