Q&A: Documenting excisions in dermatologic settings

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

For example, they should document, “The lesion is this size and we’re going to include another centimeter of an excisional margin outside the area.” That way, they can also then state height, width, and depth of the lesion.

The other thing that I like to see for dermatology is why the excision—whether it’s a circular or elliptical excision—was performed in that way. For example, I would like to see documentation similar to, “I performed an elliptical excision because the lesion appeared to be spreading and it was more elliptically sized rather than circular.”

It is important to be strict about sizes because if the physician does not give you size, and you’ve queried, and you’ve asked them to put the size together, and without a response you look at that pathology report to see what those tissue sizes were, that size might not be accurate. Once the tissue has been excised, that tissue actually shrinks, so the pathology size is probably smaller than what was actually excised. If you try to take the dimensions after the tissue has been excised from the size of the tissue area on the patient’s body, that area on the body enlarges once the tissue has been excised, and you don’t get accurate sizing. So it is very important to have correct sizes and graphic descriptions documented in order to get those dermatology excisions and incisions paid.

Editor’s Note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC,  answered this question during the HCPro webinar, “Coding and Reporting Medical Necessity: Essentials for Coders and Other Healthcare Professionals.” This Q&A originally appeared in JustCoding.