Wiki excision of masses

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trose45116

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can you code the excision of a mass with out having a path report to know the size of it. the op note does not state he went in the subq tissue at all so my only other options is the 114xx codes. if i dont have a path report what would you code
 
Size of mass

Size of mass should be documented by the physician excising the mass ... NOT by the pathology report. I would ask surgeon to dictate an addendum to specify size of mass.

In the absence of any report of size, you must default to the smallest size.

Hope that helps,

F Tessa Bartels, CPC, CEMC
 
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