Wiki calculating excsion size

paula f3

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Hello,
I code for An ASC, we have a plastic surgeon who does quite a few lesion removals. He codes the size from his pathology report , but in his dictated note he lists the size (ie 2.5 cm) , in his dictated notes he does not state margins, now I was taught that if the size is stated without margins , we are to code as stated on the op note, 2.5cm. Please corrrect me if I have misunderstood.
Any and all opinions are most appreciated.
Thank you
Paula
 
If he states the size in the op note then we do take that size, if no margins are noted then we must presume that the size noted includes the margins
 
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