Wiki Lesion margin interpretation

[fredcpc]

I am reading a medical record note, and the doctor notes 2.2 cm for the lesion, then the margin includes 0.2 from both sides. Would you interpret this as 2.2 + 0.2 x 2 = 2.6......or 2.2 + 0.2 = 2.4?

I know how to code lesion excisions, but this is a matter interpreting notes.

 

[FTessaBartels]

Best to ask the doctor

The best bet is to ask the doctor to clarify. The way I read it you would only code 2.2 cm because the word "includes" would lead me to believe the physician has already included the margins in his measurement.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[fredcpc]

Lesion Margin interp

You are probably right. Thanx.