Dermatology Coding Alert

Question: Are there written guidelines that state that the dermatologist must document the diameter of the lesion excision in the operative note, or can we use the pathology report to support a specific lesion removal code? 

Would you advise me on the best way to code for the procedures when the dermatologist does not document the specific lesion size? Should I code the smallest excision code for the anatomic site of the lesion excision?

New York Subscriber
 
Answer: While no specific guideline states that the dermatologist must document the diameter of the lesion excision, there are standards of practice you should follow for assigning codes when the operative note does not provide crucial details. 

You should code for the smallest lesion that the dermatologist documented in the operative note when the dermatologist does not provide any other specific details on the lesion diameter and/or margins he excised.

Example: The dermatologist documents that he excised a lesion measuring 3.5 cm. Because the patient has a history of malignant lesions, you know that the dermatologist also excised the area around the site to make sure he did not miss any portion of the lesion. But he did not document the exact amount he excised in the marginal areas.

Therefore, though you know the dermatologist probably excised an area greater than 3.5 cm, your best choice of code is still 11644 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm) because 3.5 cm is the only documented measurement in your records.

Another tip: You can also wait for the pathology report to determine if the dermatologist excised a benign lesion or a malignant lesion, because benign lesions reimburse at a lower rate than malignant lesion excisions.