Wiki How would you code this?-Suspicious symptomatic

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mom2all82

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Pre and PostOP Diagnoses:Suspicious symptomatic skin lesion left cheek and right lateral canthus.

Operative Findings: X has a 0.4 cm lesion on the left cheek and a 0.7 cm on the right cheek. Both have symptoms of irritation, inflammation, and growth in the recent past.

Procedure in Detail: After satisfactory anesthetic, each lesion was excised elliptically and submitted for histology. Wound closure ensued in a complex fashion with generous undermining and a multilayer closure each location. The patient was discharged. Follow up 10 days for sutures.

This is what I deal with daily. This is how all office lesion removals are documented. I don't feel that there is significant detail to justify complex closure. Am I being to harsh or can you help me locate black and white documentation that states that there needs to be more detail than this. My provider is stedfast that this is sufficient documentation.

Your help is greatly appreciated!
Thanks:eek:
 
there was a very informative webinar this week on lesions, scars, etc. that had examples of cases w/ documentation of 'complex repair' and no add'l detail was given other than the different types of suture for ea. layer closed. this did not present to be a red flag in the webinar and i would imagine because the physician documented the type of closure. it's when they do not document the type of closure, it would be left up to the coder to decipher. unfortunately in the coding world, as i too have learned, everything we code is not black and white :confused: it would make things a lot easier if it were though. i agree that documentation should be more detailed to include layers closed, degree of undermining, etc., as this would better assist with code selection and perhaps compliance, in the event of an audit. however, due to variations of dictation style, this may not always be the case. as far as this note ... he does mention 'generous undermining' which is part of complex repair per CPT description. if you feel very uncomfortable billing procedures that have little detail and your physician won't budge, talk with your office manager.
 
there was a very informative webinar this week on lesions, scars, etc. that had examples of cases w/ documentation of 'complex repair' and no add'l detail was given other than the different types of suture for ea. layer closed. this did not present to be a red flag in the webinar and i would imagine because the physician documented the type of closure. it's when they do not document the type of closure, it would be left up to the coder to decipher. unfortunately in the coding world, as i too have learned, everything we code is not black and white :confused: it would make things a lot easier if it were though. i agree that documentation should be more detailed to include layers closed, degree of undermining, etc., as this would better assist with code selection and perhaps compliance, in the event of an audit. however, due to variations of dictation style, this may not always be the case. as far as this note ... he does mention 'generous undermining' which is part of complex repair per CPT description.
 
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