Wiki coding surgeries

[hartvn]

Hello. I have recently been appointed the job of coding our surgeries and I am a little nervous and confused on how to come up the excision size from the measurements given to me... any help would be greatly appreciated.

 

[mitchellde]

Please enclose an example of what you are given on the procedure note

 

[hartvn]

example

Squamous Cell Carcinoma of the Left Upper Mandible

Excision
I. 0.6 x 0.4 x 0.2cm
II. 2.0 x 0.4 x 0.2cm

Complex Closure
3.0 x 1.0 cm

 

[kvangoor]

I would read the guidelines in the CPT book, they give good direction on code selection. For this example, page 68 would be were you find your information. Since it is a malignant lesion you would be using codes 116XX depending on location and size. The guidelines state to code each lesion seperately and to use the greatest diameter plus margins to determine the size. So I would use 11641 (for .6) and 11642-59 (for 2.0) unless there is a wider margin. Don't forget to code for the closure (12XXX)!

 

[mitchellde]

when you say the location is the left upper mandible then I am thinking bone, or is it the skin of the face in the area around the left upper mandible?

 

[hartvn]

It is the skin of the face around the mandible area.

 

[AB87]

Always remember Lesion size + margins. CPT has an example in the in Derm section of the CPT book