Part B Insider (Multispecialty) Coding Alert

Ask your physician to specify the margin excised

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 else 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 what measurement to use as the lesion, and which measurement to use as the margin? Is there a general rule?

 
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Answer: You should never try to guess the size of the margins around the lesion, says Joan Gilhooly with Medical Business Resources in Barrington, IL. 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: It's not enough for your doctor to document the size of the lesion itself, Gilhooly adds. The physician also must document the size of the margin removed.

In the absence of that information, you can use the size the physician documented. Or you can go by the size mentioned in the pathology report. -Both of those are going to be smaller than the actual size and you may end up actually undercoding,- Gilhooly warns.

What to do: Remind your physician that procedures require procedure notes. These should include indications, post-operative diagnosis, and a description of the procedure the physician performed, says Gilhooly. 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 .5 by 1.5 lesion,- including the color and size. The note should include something like, -I excised this lesion by taking an elliptical path,- and mention the margins, according to Gilhooly.