Excision of a Skin Lesion

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March 6, 2014

Question:

When coding for excision of a skin lesion (114xx, 116xx), do I use the size on the pathology report to determine the correct CPT code?

Answer:

The most accurate measurement, according to CPT, is when the lesion has not yet been excised and is still on the patient. The specimen reduces in size when it is in formalin. So reporting a CPT code with the size listed on the pathology report may result in a lower CPT code being billed and a loss of revenue.