ED Coding and Reimbursement Alert

Question: When the ED physician removes a benign lesion, how should I measure the excision size (the diameter of the wound)? Also, when should we measure the excision area — before or after the lesion goes to pathology?

Montana Subscriber

Answer: When calculating lesion excision size for coding purposes, you’re selling yourself short if you just measure the lesion: for optimal return on your coding, report the total excised diameter on the claim.

How? First, find out the exact size of the lesion. Per CPT^® code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision. Think: (excision diameter + the narrowest margins required = the excised diameter).

So let’s say the ED physician treats a lesion on the patient’s left leg. The operative report indicates that the lesion was benign; the lesion was 2.6 cm at its widest point, and the ED physician also had to remove a margin of 0.3 cm on either side of the lesion.

To come up with total excised diameter, add the lesion diameter (2.6) and the margin (0.3 + 0.3), and the diameter would be 3.2cm. On the claim, you would report 11404 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter 3.1 to 4.0 cm) for this encounter. Also, attach ICD-9 code 216.7, (Benign neoplasm of skin of lower limb including hip) to 11404 to represent the patient’s lesion.

Pre- or post-pathology? Lesions will shrink during the pathologist’s analysis, so have the physician measure and document the excision area, then send the lesion to pathology.