tci General Surgery Coding Alert - 2009 Issue 5

Reader Questions: Avoid Losing $20 Per Excision

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...

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