Health Information Management

Q/A: Documenting lesion size

APCs Insider, November 13, 2009

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Q: A surgeon excises a lesion on a patient’s back, but fails to document its size or the margins in the operative report. The pathology report lists the total size of the excised specimen, including the lesion size. May we use the pathology report as documentation for the lesion size and the margins excised?
 
A: CPT Manual introductory notes for this section state “The measurement of lesion plus margin is made prior to excision.” This requires physicians to provide the size before removing a lesion.
 
Using the pathology report as documentation for coding purposes may result in reporting of an incorrect size. CPT Assistant, August 2000, p. 5, states that pathology reports usually provide specimen size rather than size of the lesion or the excised specimen. Specimens shrink when added to formalin or other preservative. Therefore, measurements in pathology reports are not accurate and don’t provide accurate information for proper CPT procedure code assignment.
 
Query physicians when they remove a lesion but fail to document its size. Specifically, request the size of the lesion and margins. Physicians need this information to submit accurate bills for their professional services.



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