Orthopedic Coding Alert

Question: When reporting excision of benign lesions, how do we measure the excision diameters? Please also advice if it is good to measure the excision area before or after the excised tissue is sent to the pathology.

Montana Subscriber

Answer: When reporting excision of benign lesions, you should best the total excised diameter on the claim. Do not limit yourself to the diameter of the lesion. According to CPT^®, code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision, (excision diameter plus the narrowest margins required equals the excised diameter).

For example, if your surgeon treats a lesion on the patient’s left leg and the operative report indicates that the lesion was benign and was 2.6 cm at its widest point. You also read that your surgeon had to remove a margin of 0.3 cm on either side of the lesion. To be precise for the total excised diameter, you add the lesion diameter (2.6) and the margin (0.3 + 0.3), and the diameter you report is 3.2 cm. On the claim, you would report 11404 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter 3.1 to 4.0 cm) for this encounter. Also, attach ICD-9 code 216.7 (Benign neoplasm of skin of lower limb including hip) to 11404 to represent the patient’s lesion.

Make sure you report the diameters before the samples are sent to the pathology. Lesions will shrink during the pathologist’s analysis, so it is best if your surgeon can measure and document the excision area, then send the lesion to pathology.

Note: Educate surgeons on the need to dictate lesion dimensions in their operative report.    All too often, you may see masses described as being “golf-ball” sized or “pea-sized” or simply “large,” and this does not give the adequate information for code assignment.