Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Report each benign (or malignant) lesion excised separately. Selection of the CPT code for excision is determined by measuring the greatest diameter of the apparent lesion plus the margin required for complete excision. The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician’s judgment.

Check out this three-step guide to choosing the proper lesion excision code each and every time you code.

ID Lesion Type

You can’t tell if a lesion is benign or malignant, which is why you should wait on the pathology report before choosing a CPT code for excision. Sometimes, the internist may not send the lesion to a pathologist because he is confident that the lesion is benign. When this occurs, you should choose a benign lesion excision code. Always let the physician make the final decision on lesion pathology. The coder should never, under any circumstances, decide the pathology of a lesion from the operative notes.

Pinpoint Body Area

Once you have determined lesion type, you need to locate the body area where the physician excised the lesion. For coding purposes, CPT breaks lesion excision codes into four body areas:

• trunk, arms, legs
• scalp, neck, hands, feet, genitalia
• face, ears, eyelids, nose, lips, mucous membrane
• face, ears, eyelids, nose, lips

Formulate Total Excision Area

Next, you’ll need to measure the total excision area of the lesion. Your code choice depends on the size of the lesion excision area.

Follow the proper steps toward selecting a CPT code for excision, claims can be a breeze. But if one of those steps causes you to stumble, chances are good that your code choice will be inaccurate.