Debra Posted Fri 12th of December, 2014 09:54:11 AM
I frequently have to query my physician to include the size of the excision when my docs do this type of surgery.
As I usually do, I am querying my physician again to include size in this op note. But a specific question for cpt code 21555, the description says "excision, tumor, soft tissue of neck or anterior thorax, subfascial (intramuscular); less than 3 cm."
If there is no size documented, am I allowed to use this code? "The size states 3 cm or less", I wasn't sure where to look for specific guidelines for something like this.
SuperCoder Answered Fri 12th of December, 2014 10:14:39 AM
Thanks for your question. You should have the most specific and accurate documentation when billing. 21555; Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm does state that the excision is 3 cm or less but you should not select this code without proper documentation. Your provider may have completed an excision that was larger than 3 cm and choosing this code would be undervaluing the work of your provider. Hope this helps.
Debra Posted Fri 12th of December, 2014 10:29:54 AM
Thank you for quick response.
I just received 1 more question in relation to this. I just received a response back from my physician. He stated the measurements are the same as in the pathology report. He did not take any margins.
Am I allowed to used these measurements or would they have to be documented in the operative note as well.
I did pull the path report and I have the exact measurements there?
SuperCoder Answered Fri 12th of December, 2014 11:13:08 AM
You are welcome. He should document it in his note. If you were to be audited the documentation would be incomplete. Advise your provider to do an addendum or a chart note specifying the excision size.