If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
My doctor documented he excised a 7-9 mm lesion. In the op note he states that he marked out an elliptical lengthwise incision around the lesion approximately 2 cm in length and 1 cm wide. What size do I go by?
You measure the length of the lesion, plus the margins on each end. When he says he "marked out an elliptical lengthwise incision around the lesion approximately 2 cm in length," does he mean he made a 2 cm margin? If so, then 7 (or 9?) + 2 + 2 = 11.
I've had the issue on multiple occasions where the physician is not precisely measuring (or at least not documenting the measurement) on the op note. I verify with the pathology report, which always states the exact size.
I typically await the pathology report anyway to determine if benign or malignant.