You should never label a lesion malignant on your own.
Patients who report to the emergency department for lesion removal present for special challenges for the coder who normally does not have time to wait on pathology reports prior to choosing a CPT code for the procedure. You should also know how CPT breaks the body down when a patient reports with an oozing scab or some other sort of lesion.
Here are some expert guidance to help you in your lesion removal coding.
The starting point: As a coder, you need various pieces of information before you can choose a proper lesion excision. First, find out the anatomical area of the lesion. For coding, CPT (Source CPT http://www.supercoder.com/ )breaks down lesion removals into various categories:
Lesion is benign or malignant: You should never have to choose between a benign and malignant lesion. It’s unethical and illegal to diagnose any patient with any condition minus the burden of proof. The only way to be sure a lesion is malignant is to wait for a path report. This isn’t a problem in a dermatologist’s or plastic surgeon’s office. However, ED charts are normally sent for billing within a day or two, so you have to default to the benign (removal) codes, unless you have pathology confirmation that the lesion is malignant.
You should ensure that the physician signs off on the pathology of the lesion, even if it is benign. The physician needs to be the one to document the findings.
Measuring total removal size: If you are reporting only the length of the lesion while choosing a removal code, you are selling the ED short. When determining the proper size of the excised lesion, the provider should add together the (greatest clinical) diameter of the lesion in addition to the size of the margins (required).
Patients who report to the emergency department for lesion removal present for special challenges for the coder who normally does not have time to wait on pathology reports prior to choosing a CPT code for the procedure. You should also know how CPT breaks the body down when a patient reports with an oozing scab or some other sort of lesion.
Here are some expert guidance to help you in your lesion removal coding.
The starting point: As a coder, you need various pieces of information before you can choose a proper lesion excision. First, find out the anatomical area of the lesion. For coding, CPT (Source CPT http://www.supercoder.com/ )breaks down lesion removals into various categories:
Lesion is benign or malignant: You should never have to choose between a benign and malignant lesion. It’s unethical and illegal to diagnose any patient with any condition minus the burden of proof. The only way to be sure a lesion is malignant is to wait for a path report. This isn’t a problem in a dermatologist’s or plastic surgeon’s office. However, ED charts are normally sent for billing within a day or two, so you have to default to the benign (removal) codes, unless you have pathology confirmation that the lesion is malignant.
You should ensure that the physician signs off on the pathology of the lesion, even if it is benign. The physician needs to be the one to document the findings.
Measuring total removal size: If you are reporting only the length of the lesion while choosing a removal code, you are selling the ED short. When determining the proper size of the excised lesion, the provider should add together the (greatest clinical) diameter of the lesion in addition to the size of the margins (required).
