Reader Questions:
Avoid Losing $20 Per Excision
Published on Sat Apr 04, 2009
Question: I just received a pathology report back that reads: "The largest segment measures 3.5 x 3.5 x 2.0 cm. A second fragment measures 3.0 x 3.0 x 3.0 cm and then in aggregate, the smaller fragments measure 3.5 x 3.0 x 2.0cm." The surgeon excised these lesions from the patient's back and neck. How should I code this? Missouri Subscriber Answer: You cannot code this excision solely from the pathology report. You need to go back to the physician's record of the procedure. You should select the appropriate lesion excision size code based on the physician's report. Once the specimen is put in the jar and sent to pathology, the specimen shrinks down, sometimes to half its original size. CPT's excision sizes, including margins, are based on the physician's measurements at the time of the excision. Your surgeon should always measure an excision and document it with a statement, [...]
