You know that is the way I used to think Ftessa.... but I have been given helpful information including from CPT, Because the lesions could be fusiform wedge excisions & even elliptical , these excisions are much wider than usual, it's like looking at the shape of an eye, very wide and then thins out at edges, this is done so as to minimize scarring, & other reasons so a much larger excision is done, and if the lesion size plus the width of the narrowest margins is not clearly indicated , what you can be doing is overcoding by using the size on the path. report ( see some examples below)
The Coding Institute 2008 Vol. 11 No. 5
QUESTION: excision of lesion sample op report: patient taken to operating room patient had two converging semi elliptical incisions were created in the subcutaneous tissue. the encompassing skin wedge and soft tissue mass were meticulously dissected free with blunt and sharp scissors. it was noted to go into the fat tissue, it was a hard fibrotic mass. we further explored the area no other suspicious appearing lession was noted. the wound was flushed copiously we the closed the wound.
Path report: received is an elliptical portion of tan tissue measuring 2.6cm x 9 x 1.2cm, a centrally placed ulcerated lesion measures 3 x 3mm. no orientation identified. the surgical margins are inked.
RESPONSE: Choosing a CPT code from this report won't be simple. the provider has the responsibility to measure the lesion with margins prior to excision of the lesion, lesions shrink when the pathologist analyzes them, which means the 3mm x 3mm in the sample path report is probably smaller than the lesions actual size, but if the surgeon can't provide the actual measurements, you may have to code this excision conservatively by using the 3mm x 3mm lesion measurement because you have no documentation of the narrowest required margin or size of lesion.
Another example:
"Note that the "excised diameter" does not represent the dimensions of the total fusiform excision, which is 5 by 1.1cm. Coding is determined by the excised diameter definition. If this is confusing consider how this lesion would be excised if the defect was to be reconstructed with a skin graft. The excision would measure 2.1 by 1.1 cm ie, the amount of tissue resection to adequately excise the lesion (not the 5 by 1.1cm fusiform excision) This is where the definition of excised diameter should make sense.
CPT ASSISTANT: This is where the two sample diagrams from the CPT book comes into play (diagrams attached)
CPT code selection is based on the size of the
lesion prior to excision, including surgical
margin, recorded in centimeters (cm)
Code selection is determined by measuring the
greatest clinical diameter of the apparent lesion plus
that margin required for complete excision (lesion
diameter plus the most narrow margins required equals
the excised diameter).
4. The margins refer to the most narrow margin required
to adequately excise the lesion, based on the
physician's judgment.
5. The measurement of lesion plus margin is made prior
to excision.
AMA 2008 Professional Edition, page 53-54
How coding from Pathology Reports lead to
Lesion Measurement Overpayment
Lesion Size…
Size of Lesion Size of Specimen
The specimen size is much larger than the actual lesion size. If the specimen size is the only recording on the pathology report and
the CPT code is selected from the pathology report, then an up-coded CPT is billed to the payer resulting in an overpayment.
OR
How coding from Pathology Reports lead to
Lesion Measurement Underpayment
Size of Lesion Size of Specimen
The specimen size can be the lesion size. The specimen size recorded on the pathology report is likely to contain a less accurate measurement,
due to the shrinking of the specimen or to the fact that the specimen may be fragmented, resulting in undercoding and underpayment.