General Surgery Coding Alert

Question: We-re confused about how to figure out the margin size when the physician excises lesions. Usually, the physician will give us the size of the lesion itself -- or no measurement at all. The physician sometimes includes a note that says something like: "2 cm x 1.5 cm x 0.5 cm." And sometimes, we get measurements from the pathology report. How do we figure out which measurement to use as the lesion, and which measurement to use as the margin?

New Jersey Subscriber

Answer: You should never try to guess the size of the margins around the lesion. Your physician is supposed to document the margin size. You should choose your code by measuring the greatest diameter, plus the margin required for incision.

Important: You won't have enough information if your doctor documents the size of the lesion itself. The physician must also document the size of the smallest margin removed, per CPT instructions.

Without that information, you can use the size the physician documented, or you can go by the size mentioned in the pathology report. Beware, however, that both of those measurements are going to be smaller than the actual size, and you may end up actually undercoding.

What to do: Remind your physician that procedures require complete notes. These should include indications, postoperative diagnosis, and a description of the procedure the physician performed. That goes for minor procedures as well as major ones.

In the case of lesion excisions, a good note will say something like: "On the right forearm, midway between this and that landmark, there was a 0.5-cm by 1.5-cm lesion," including the color and size. The note should add something like, "I excised this lesion by taking an elliptical path," and mention the width of all margins.