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Posted By lana on 05-01-2007, 12:43:00 in Ob-Gyn

-----Original Message-----
From: L. Flatt [mailto:lflatt@cookevilleobgyn.com]
Sent: Monday, April 30, 2007 2:56 PM
To: CODING LIST/OB/GYN (obgyn@codelist.net)
Subject: lesion removal


op report states incision of 4.5 cm. Path report states ....approx 3.0 cm
in greatest dimension. I know the intermediate repair code would be based
on 4.5 cm. The actual excision of lesion - would that be for 3.0 lesion or
4.5?

Comments (5)
Posted By lana on 05-01-2007, 21:23:00
Thanks for all the responses. It helps.
Posted By rebecca on 05-01-2007, 20:41:00
If the MD documentation states the size , I would code the size from his
notes.

The coding alert for IM OCT 2005 states to use the MD's progress notes if
size is indicated.

Use the size of the speciman from the Path if the MD does not indicate the
size in the progress note.

Rebecca Lopez CPC
Bright Medical Associates
Phone # (562) 947-8478 ext 2118
Fax# (562) 943-3757
Posted By Arlene on 05-01-2007, 19:21:00
the size of the total excision which is the lesion plus the margins.
Posted By lana on 05-01-2007, 18:53:00
I did read that. All the information I have is the documentation of path
specimen as 3cm (although I know the specimen shrinks when placed in the
formaldehyde, I don't know how much). I also have a documented incision
length. My question is do I bill the size of the lesion as documented from
the path report or from the size of the incision?
Posted By Arlene on 05-01-2007, 18:09:00
There is a description in the Integumentary System section in the CPT book on how to determine the size for coding excision of lesion. You have to include margins not just the size of the lesion. If you read that I think you will find your answer.
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