Q: Is it appropriate to wait for a pathology report before coding?
A: Absolutely, I encourage it.
Q: If my surgeon does not document the size of a lesion and the margins, can I take them from the pathology report? 4
A: Ideally, this is not good practice. When specimens are sent to the lab, they are placed in a solution that may cause the specimen to change in size, therefore the size documented in the pathology report could potentially be inaccurate. Best practice is to query the provider for that documentation. Its important to remember that queries should be written documents and they should be placed in the patient's medical record to support the coding as well.
Q: My coworkers and I disagree about how excisions of sebaceous cysts should be coded. Should these be reported using integ or musculoskeletal CPTs?
A: Sebaceous cyst should be captured from the integumentary section of CPT. These are reconsidered cutaneous and there are several CPT assists to support this.
Mary Bort, CPC, CPMA, CANPC, CASCC, COSC
During her free time, she loves to do crafts, enjoys the outdoors, and the Broncos! She has 4 daughters, and 10 grandchildren which light up her life.