Internal Medicine Coding Alert

Question: The new CPT guidelines for excision of a benign or malignant lesion state that you should select the CPT code based on the size of the lesion plus margin. Should I get this information from the physician documentation or can I take it from the pathology report?

Kentucky Subscriber

Answer: You should use the lesion and margin measurements from the physician documentation when reporting the 11400 series (Excision benign lesions) and the 11600 series (Excision malignant lesions). If the physician does not note the measurements, ask her to add an addendum to the documentation that includes the size of the lesion.

If the physician did not record the size at the time of surgery and cannot provide you with this information, you can use the size recorded in the pathology report. But that may cost the practice money it should have received in reimbursement. Lesions shrink when placed in formaldehyde. Because the codes are based on size and are separated by only 0.1 centimeter, you may be forced to select a lower code and lesser reimbursement if you use the size recorded in the pathology report. (For more information on the 2003 lesion coding changes, see "Keep Your Ex's and In's Straight When Coding Lesion Removal" in the January 2003 issue and "CPT 2003: Lesion Measurement, Finger Sticks Top List of Changes for Internists" in the December 2002 issue of Internal Medicine Coding Alert.)