December 19, 2019
Our coder sometimes uses measurements listed in the pathology report for lesion excisions, because the measurements are unclear or missing in the procedure note. Is this ok?
No, for several reasons. Once removed, tissue(s) shrink so don’t depend on the measurements listed in the pathology report as it will most likely be smaller than the actual excision. And It is always necessary to have the measurements of the excision documented in the procedure note. So, if you have questions or need documentation clarification, ask your provider for help so he/she can amend the note prior to billing if necessary.
Excision means lesion plus margins (the narrowest margin), not just lesion itself. CPT 2019 gives us several illustrations on page 83 of how to calculate for these codes, so make sure to share this information with your coder and provider.
*This response is based on the best information available as of 12/19/19.