General Surgery Coding Alert

Question: If our surgeon removes a sebaceous cyst from the back that measures 2.5 x 1. 5 x 0.5 cm, what dimension should we use to select the proper skin lesion code? Do you determine the size the same way if it's a lipoma, and how should we measure for repair codes?Texas SubscriberAnswer: Whether the surgeon removes a cyst or lipoma with the lesion measurements you gave, you should select the code based on the largest dimension (2.5 cm). If the surgeon also documents the width of the narrowest margin, however, you could add that to the overall excision size. In other words, not documenting the margin means you're leaving money on the table.Add margins: Whenever the surgeon excises a skin or soft tissue benign or malignant neoplasm, you should determine the size for coding purposes based on the largest lesion diameter plus two times the narrowest margin. Looking at [...]