Dermatology Coding Alert

Question:  I just received a pathology report back that reads: "The largest segment measures 3.5 x 3.5 x 2.0 cm. A second fragment measures 3.0 x 3.0 x 3.0 cm and then in aggregate, the smaller fragments measure 3.5 x 3.0 x 2.0cm." The surgeon excised these lesions from the patient's back and neck. How should I code this?

Missouri Subscriber

Answer:  You cannot code this excision solely from the pathology report. You need to go back to the physician's record of the procedure. You should select the appropriate lesion excision size code based on the physician's report.

Once the specimen is put [...]

- Published on 2011-09-09