Wiki Lesion removal sizing

[mwells2020]

I have a question regarding what measurement everyone uses for a lesion removal? I have always coded and billed a lesion by the width (i.e. 2.4 x 1.6 x 0.9) I would code with the measurement of 2.4. My Dr. that removed this lesion said to use the measurement of 1.6 instead. I have never billed this way before and wondering if that is how anyone else bills. Thank You for your time in advance!

 

[thomas7331]

Assuming by 'removal' you mean excision, then per CPT, the measurement should be "the greatest clinical diameter of the apparent lesion plus that margin required for complete excision." So I would agree with you that you would use the 2.4 measurement since that is the largest dimension documented.

 

[cgifford]

Agreed, when more than one dimension of a lesion is provided, use the largest side (e.g. 2.0 x 1.2 x 0.5cm) use 2.0cm as the lesion size.

Lesion size plus margins (e.g. 2.0cm lesion plus 0.2cm margin plus 0.2cm margin= 2.4 excised diameter

examples are also shown in the CPT book, Measuring and coding the removal of a lesion in the excision section.

Colleen Gifford, CPC, CPCD, CPB