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Wiki Help coding exsisions

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pajohnson

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Hi All-
I need some help in coding excisions. I have a left sided 1 x 4 cm ulcerative lesion on the left helix. It is basal cell carcinoma. How do I calculate the excised diameter? There were no margins mentioned in the Op report, only that an elliptical incision was made around the skin lesion and this was removed in toto including an underlying portion of cartilage.
Please explain in simple steps :o
Thank you
 
if the provider does not give you the lesion size and the margins then we must assume that the size stated in the note is the excised diameters. you would code from the largest measurement. for your example it is a 4cm excision.
 
So, really I would need to query this Op report to get the margins for the correct excised diameter. He wants to code 11643 which is 2.1-3cm. So that does not make any sense if my largest is 4 cm? Am I correct?
Thanks for your help!
 
You are correct, that CPT does not correspond with the lesion size. If all else fails you could look at the path, but remember, this isnt a "true" size as the lesion shrinks a bit when its put in the formalin.
____________________
Angela, CPC
 
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