I always second guess my self when coding lesion removals. I code for a Family Practice Clinic and the documentation isn’t the best re: size excised. Below is the procedure note. I’m coding 11642 1.1-2.0. Or should I be adding the 1.5x 1.5? Any help would be greatly appreciated. Thank you.

PREOPERATIVE DIAGNOSIS: Right temple basal cell carcinoma.
POSTOPERATIVE DIAGNOSIS: Right temple basal cell carcinoma.
PROCEDURE PERFORMED: Wide excision of right temple basal cell
carcinoma.
SURGEON: Dr. A
ANESTHESIA: Local.
INDICATION FOR PROCEDURE: The patient is an -year-old , who
presents with a lesion on the right temple just above hairline. It has been there for over a year. This was biopsied and proved to be a basal cell carcinoma. was sent here for excision.
OPERATIVE FINDINGS: A 1.5 x 1.5 _____ cm basal cell carcinoma excised
with a 3.5 x 1.5 cm ellipse.
DESCRIPTION OF PROCEDURE: The patient was laid in the supine position.
Patient is prepped and draped sterilely. I anesthetized the skin around the right basal cell carcinoma. I then made a 3.5 x 1.5 center ellipse, which grossly appeared to include the entire skin lesion. This was passed off for specimen. Hemostasis was confirmed with cautery. I then closed the ellipse with interrupted Prolene sutures. I will see her back in a week for pathology review and potential suture removal.

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Dr. A

CC: Basal cell carcinoma .