When coding an excision of lesion that has a pre op size of 0.5 cm x 0.50 cm with a post op size of 0.6 cm x 0.6 cm. Appropriate margins of 0.1. The doctor document all this and a final repair length of 1.5 cm. My question is would I code it using the 0.6 or the 1.5. I am confused if I use the post op or the final repair length.
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Wiki Excision lesion
- Thread starter lindafay1123
- Start date
osbornes
Contributor
I code from the size documented on the pathology report. I hope this helps
Pam Warren
True Blue
Well, I go about this a bit differently.
The lesion size is 0.5 x 0.5 preop and if you add on the margin of 0.1, you get your post op size, which indicates the size of the defect. That's what you code. I don't code by the repair length, I code by the size of the elliptical defect.
I never code from the pathology report because the tissue sample shrinks and you end up undercoding. The best way is to instruct your provider how to document the size of their excision so there's no guessing.
The lesion size is 0.5 x 0.5 preop and if you add on the margin of 0.1, you get your post op size, which indicates the size of the defect. That's what you code. I don't code by the repair length, I code by the size of the elliptical defect.
I never code from the pathology report because the tissue sample shrinks and you end up undercoding. The best way is to instruct your provider how to document the size of their excision so there's no guessing.