Wiki guidelines for dermatology coding

[jath21]

I have a question: Can you look at the path report to determine the size and depth of a lesion/tumor/mass? It has been explained to me in seminars that the provider has to document the size and depth in the operative report and if not documented the coder is to go to the smallest size and code that. If this is true does anyone know where I can get the hard proof. I know that you have to wait on path to code malignant or benign.

 

[lshannon]

If size, etc. of a lesion is not documented in the op report, you can use the information in the path report. There will be "shrinkage" typically, so the size of a lesion in the path report is usually smaller than what was actually removed, but if not reported on the op report, you have to go with what is documented in the path report.