Hammon Marilyn
University of Oklahoma Health Science Center, Oklahoma City, USA.
J Okla State Med Assoc. 2006 Mar;99(3):134-5.
Clear and precise documentation is essential to accurately code and bill for excision of benign or malignant skin lesions. Detailed documentation is crucial for capturing the full allowable reimbursement when the procedure involves more than a simple closure. For each lesion, only one type of removal may be reported, whether it is destruction, debridement, paring, curettement, shaving or excision. If an initial attempt to remove a lesion by a less invasive procedure is immediately followed by a more invasive lesion removal, only the more complex, definitive procedure may be billed. According to the Current Procedure Terminology manual (CPT), an excision of a skin lesion is defined as "full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed." Changes in recent years now allow code selection based on the greatest clinical diameter of the lesion plus the narrowest margin required for adequately excising the lesion, "based on the physician's judgment." According to CPT, the "measurement of lesion plus margin is made prior to excision".
清晰准确的记录对于准确编码和计费良性或恶性皮肤病变切除术至关重要。当手术涉及的不仅仅是简单缝合时，详细记录对于获取全部可报销费用至关重要。对于每个病变，无论采用的是破坏、清创、削除、刮除、剃除还是切除，只能报告一种切除类型。如果最初尝试通过侵入性较小的手术切除病变后紧接着进行了更具侵入性的病变切除，则只能对更复杂的确定性手术进行计费。根据《现行手术术语手册》（CPT），皮肤病变切除术定义为“全层（穿过真皮）切除病变，包括切缘，并且在进行时包括简单（非分层）缝合”。近年来的变化现在允许根据病变的最大临床直径加上充分切除病变所需的最窄切缘来选择编码，“基于医生的判断”。根据CPT，“病变加切缘的测量在切除前进行”。
