An outpatient lesion excision note omits lesion size, which is requ…

Question

An outpatient lesion excision note omits lesion size, which is required to select the correct CPT excision code family. What should the coder do?

Accepted Answer

Withhold size-dependent CPT specificity until lesion size is documented in the operative note or clarified — Lesion excision CPT codes care about centimeters, not vibes. If the op note forgot the size, do not eyeball pathology or pick the biggest code—get the measurement documented first.

Answer

Estimate size from the pathology specimen measurements and assign the CPT code

Answer

Assign the highest-level excision code to avoid undercoding

Answer

Code only a biopsy CPT because size is missing

An outpatient lesion excision note omits lesion size, which is required to select the correct CPT excision code family. What should the coder do?

Short Explanation

Full Explanation