Wiki Proof needed - lesion excision

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ENostrant11

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Hello! I'm hoping someone in this group can help me in obtaining referenced articles (preferably from CPT Assistant) to prove my point to an auditor that you cannot code a lesion excision based on the size of the incision documented in the operative report. My providers are not great at documenting lesion size and margin size so it is my understanding that if I do not have this information, the measurement noted in the pathology report can be used for code selection.
However, even when they do document lesion size and margin size, I am still being told to use the incision size to determine code selection. This can't be right, can it?? I need some credible references to make my point. Thanks!!
 
Do you have a copy of the CPT book? There are detailed instructions in there at the beginning of the section on excisions which clearly state that the measurement to be used is the lesion diameter plus margins. Nowhere does it state that the incision length can be used. I would start by showing them that since it's the primary and definitive source for guidance on CPT code assignment.

There was an article some time ago in CPT Assistant (I no longer have access to that so I can't give you the exact citation) which stated that in the absence of a documented lesion size that it was acceptable to use the measurements from the pathology, but that they recommended avoiding this if possible because the specimens tend to shrink and can be smaller than the original lesion.
 
Hello, I am facing a different issue.

For excision procedures, our surgeon is documenting the overall size of the lesion as below.

Procedure: Excision of the 5.7cm lipomatous multilobulated left posterior thorax sub fascial tissue neoplasm
Preop diagnosis: 5.7cm deep subfascial soft tissue neoplasm.
Post op diagnosis: Same
Patient was prepped .........and Mass was located on the surface of the muscle and evacuated as a single specimen. It was located below the platysma entire specimen, including deep margin was removed and sent for path.

My question:
Can I code this report based on just the details mentioned at the beginning of the OP report (as above- under the procedure/ Preop diagnosis).
OR
Should I request the surgeon to make addendum and update the exact measurements under the detailed operative note? - is this mandatory?

Any advice?
 
You can code from the measurement that is already documented, especially given that the provider has confirmed this in stating that the postoperative diagnosis was the same. It wouldn’t serve any purpose to ask the provider to repeat the information that was already given.

The purpose of the guidance that is usually given regarding coding only from the operative report is to ensure that the procedure actually performed matches the procedure named in the header. It doesn’t mean that you can’t use relevant information in the header or other parts of the record.
 
Thankyou for your response :).
I was debating to code as is, as I couldn't find any specific guidelines anywhere regarding this, to explain the surgeon.

My thought when I posted this was - if a neoplasm is excised, and the operative description states the size of the lesion along with the margin, then the CPT code and reimbursement value changes.
And you are right - the provider has confirmed this in stating that the postoperative diagnosis was the same!
I will just request them to consider adding margin to make it complete, for future claims.
 
Thomas7331, you've been so helpful with all my lesion questions. I'm hoping you can help me with one more! :)
Do you happen to have any articles on how to code a lesion re-excision? I thought you take the previous excised diameter and then add the margins that were taken during the re-excision. Example:
Original excision = 2.0 cm
Re-excision = 0.5 cm margins
Would the re-excision size be 3 cm? This would lead me to 11643
Or would I just code for the size of the margins, 0.5 cm(x2)? This would lead me to code 11641.

The re-excision was not done during the post-operative period, so no modifier is necessary.
Any help is appreciated!!
 
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