Wiki Lipoma Excision

[svms]

As I usually do, I am querying my physician again to include size of excision in his op note. But a specific question for cpt code 21555, the description says "excision, tumor, soft tissue of neck or anterior thorax, subfascial (intramuscular); less than 3 cm."

If there is no size documented, am I allowed to use this code? "The size states 3 cm or less", I wasn't sure where to look for specific guidelines for something like this.

 

[svms]

After just querying the physician he said the exact measurement is documented in the pathology report. There would be no margins he told me.

Am I allowed to use the pathology report to pull the measurement of the excision, or does it also need to be documented in the operative note?

 

[jwiles66]

You can use the pathology report for specific size of lesion, however, you should have your physician append the op report to document the size also.