Wiki excision or not?

[chasarmil]

How you would code this?

In the exam the provider states patient has 4 pigmented lesions each measuring .25cm.

The procedure note states local anesthesia was infiltrated into the base of the lesions. The lesions were each removed. Simple repairs of the defects were performed.


No other documentation available and no path report.

 

[mitchellde]

You cannot report a removal as there is no indication of an incision. You also have no idea if this was a shave or excision. I see nothing to code for this, I would send the report back for revision.

 

[chasarmil]

Thanks. That's what I was thinking, but just wanted to make sure. This provider documents very little when it comes to his excisions.