Question

Operative Report: INDICATIONS FOR SURGERY: The patient has a dysplastic nevus on the right upper abdomen. The area is marked for elliptical excision with gross normal margins of 4 to 6mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars is drawn. The patient observed these marks in a mirror to understand the surgery and agrees on the location and we proceeded. PROCEDURE: The area was infiltrated with local anesthetic. The area is prepped and draped in sterile fashion. The dysplastic nevus right upper abdomen lesion measuring 2.2 cm with margins is excised as drawn, into the subcutaneous fat. Suture is used to mark the specimen at its medial tip, and labeled 12 o'clock. This is sent for permanent pathology. Meticulous hemostasis is achieved using light pressure. The patient tolerated the procedure well. What is the correct CPT® code to report for this example?

Answer 1

To find the correct CPT® code for the excision of a dysplastic nevus, you would refer to the integumentary section of the CPT manual. Codes vary based on lesion being benign or malignant and are subdivided by lesion size. The lesion described is 2.2 cm including margins, which would fall into a specific size range in the code sets for benign (11400-11446) or malignant (11600-11646) lesions.

Step-by-step explanation:

The correct CPT® code to report for the excision of a dysplastic nevus (an atypical mole that may resemble melanoma) on the right upper abdomen with a size of 2.2 cm including margins would be determined by the specific details of the procedure. Based on the description you've provided, it sounds like the procedure would be coded with one of the codes from the integumentary section of the CPT® manual, which covers skin-related procedures.

When looking at the CPT® manual, there are different codes for excision of benign lesions versus malignant lesions, and these codes are further subdivided based on the size of the lesion excised. Since we don't have enough information to determine whether the nevus was benign or malignant before the pathology report comes back, we would need to know that to provide an accurate CPT® code. However, if we assume this is a benign lesion, we would look at codes in the range 11400-11446 for excision of benign lesions. If the lesion were suspected to be malignant, we'd look at codes in the range 11600-11646 for excision of malignant lesions.

Furthermore, in coding for this procedure, it's important to note that the lesion size combined with the margin is taken into account when selecting the correct code. Since the report stated that the lesion measured 2.2 cm with margins, a lesion of this size would likely fall into a specific range within those code sets previously mentioned.