Vague Documentation Hurts Skin Lesion Coding

Question: How would you code the following?

“Attention was paid to a 6mm diameter cystic structure of the right anterior neck region. A skin marking pencil was used to draw a dotted line around the periphery of the lesion as well as a proposed excision of a fusiform wedge-shaped area of skin over the mid portion of the cyst was added to closest to the skin, the excision of skin measuring approx 1.8cm x 0.3cm, the subcutaneous tissues and dermis were approximated through the use of interrupted sutures 5-0 chromic catgut, skin edges approximated through use of running sutures 6-0 nylon.”

So how would I first code the excision? Should I code the 6mm size or the 1.8cm size? And shouldn’t it mention the size of the repair? Intermediate or complex?

Answer: First, it would be well worth your time to go back to the physician and educate her on what she should make absolutely clear in the documentation to avoid confusion in this case and future ones. It’ll save you both headaches in the long run.

If it is impossible to get clarification, you are forced to code what IS documented. So for size, as I understand your excerpted note, the key phrase is: “the excision of skin measuring approx 1.8cm x 0.3cm.”

Again, without clarification we are forced to assume a simple repair. According to CPT, simple repairs include partial or full thickness damage to the skin and/or subcutaneous tissues, which is all that is mentioned in your note.

Intermediate repairs include deeper layers of the subcu and nonmuscle fascia.