Health Information Management

Do not use pathology measurements to report a lesion's size

APCs Insider, January 19, 2007

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Do not use pathology measurements to report a lesion's size

QUESTION: We are a hospital facility. When a physician performs a procedure to remove a mass, we code it using the CPT code range 11400-11403 based on the pathology findings. Is this correct? Payers deny our claims because the referring physician is the one who obtains the authorization for the procedure that is going to be performed, for example, removal of a mass (chest wall), procedure code 21555.

Can we report a code based on the diameter of the mass (i.e., the pathology report findings)?

ANSWER: Refer to the most current CPT Manual guidelines under the section "Excision, Benign Lesions; Excision, Malignant Lesions." It states "the measurement of lesion plus margin is made prior to excision."

The August 2000 issue of CPT Assistant states, "The physician should make an accurate measurement of the lesion at the time of the excision, and the size of the lesion should be documented in the operative report. A pathology report is less likely to contain an accurate measurement due to the shrinkage or fragmentation of the specimen."

In addition, in 2003 an FI published a Q/A which states:

"Q: What measurements do the FIs look at for accurate payment?
A: Educate physicians to provide measurements prior to the excision of the lesions. Pathology measurements are not the most accurate."

The bottom line, from a compliance/CPT accuracy/APC revenue integrity standpoint, is that you should not use pathology measurements to determine the size of the lesion when the surgeon does not provide the lesion's measurements. Educate physicians to provide measurements prior to the excision of lesions. The physician can document these measurements in the history and physical, operative note, or operative report. It's critical to provide feedback to your coding and physician staff regarding compliant documentation to ensure your facility's APC revenue integrity.

If you continue to use inappropriate pathology sizes when the surgeon does not provide any, remember this scenario: the specimens shrink, the excised diameters shrink, and your APC revenue shrinks.

To correct the problem going forward, perform a review of 25-50 integumentary procedures (lesion excisions and defect repairs) to assess the documentation landscape, CPT code reporting, and reliability of CPT code transfer. Based on these results, develop an action plan with education for the physician, coders, and compliance staff. Perform a follow-up assessment to benchmark success and risk.



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