Wiki Excision of lesion no biopsy

[Radcoder86]

My doctor marked that he did an excision for a benign lesion (11402) but in the note it states he removed a cyst with benign appearing sebaceous material and they decided not to send to pathology, he also didn't note the excised diameter on the chart note. So my first question is, can you code an excision as benign if you don't send it to pathology? Second, would using code 10040 be more appropriate?

Thanks!

 

[CodingKing]

10060 may be appropriate. 10040 is acne surgery.

I&D of Abscess, one of the examples is cyst. Although if it was cut out with margins vs just cut into and drained i'm not sure 10060 would be appropriate. Excision is defined as as full-thickness removal of the lesion, including margins

If it was an excision and he didn't measure it he would not be able to bill a 11402 (benign lesion trunk, arms or legs 1.1-2.0cm diameter). No measurements means you have to code to the smallest 11400 (.5cm or less). Measurements should be made prior to excision. no guessing.

Sounds like you may need to talk to the physician about proper documentation of lesions.

 

[Radcoder86]

Thank you!