Wiki Lesion or tumor size

[graciejean]

The size of the soft tissue tumor ie 3cm x 9cm of the back is listed under the procedure title only. The size is not stated in the body of the op report. From a compliance standpoint if the size of the tumor is not stated in the body of the op report but only noted under the procedure title is that acceptable to bill any lesion excision codes or soft tissue tumor codes?

 

[FTessaBartels]

Okay

If it's ANYWHERE on the operative note, I consider that the size of the lesion has been documented. I will not take the size of a lesion from path report. Our physicians have been trained that if they must specify the size.

Hope that helps.

F Tessa Bartels, CPC, CEMC