Ophthalmology and Optometry Coding Alert

Question: When determining the size of an excised lesion, should I go by the operative report or by the pathology report? Our ophthalmologist says that the lesion area excised was larger than the pathology report says.

Florida Subscriber

Answer: Dont wait for the pathology report for your information about a lesions size unless no other source is available. Once the surgeon cuts the tissue out, the lesion loses its tension and gets smaller. The formalin used to preserve the tissue before it goes to the lab can shrink the sample even further. So if you wait for the path report to code, the lesions will be much smaller, and youll be kissing well-deserved payment goodbye.

Use the lesion and margin size before the excision, as documented by the ophthalmologist in the operative report, to arrive at a lesion excision code.