# Need help to code this: Please help



## KristieStokesCPC (Jun 30, 2008)

SUBJECTIVE:

CC:Ms. X is a 56-year-old female.  

Past Medical History / Family History / Social History: 

Past Medical History: 

Skin cancer: multiple basal cells have been excised; 

Current Problems: 
Basal cell carcinoma 
Dupuytren's contracture 
Lipoma, of skin and subcutaneous tissue, NEC 
Unspecified skin lesion 

Allergies: 
Codeine:
Hydrocodone/Acetaminophen:

Current Medications: 
Darvocet-N 100 Tablet Take 1 tablet(s) by mouth q 4 to 6 hr prn 
Mobic 7.5mg Tablet Take 1 tablet(s) by mouth daily 

OBJECTIVE:

Vitals: 

Current: 4/10/2008 5:20:24 PM
Ht: 66 inches;  Wt: 138 lbs;  BMI: 22.27
T: 98.7 F (oral);  BP: 126/74 mm Hg (left arm, sitting);  P: 71 bpm (left arm (BP Cuff), sitting);  R: 14 bpm

Procedures: 
Basal cell carcinoma 

Procedure Note: 
Informed consent obtained in writing.  She expresses understanding that a scar may remain after the lesion is removed.  Sterile technique is observed.   
Malignant Lesion #1 is a basal cell carcinoma located on left anterior shoulder.   The lesion is removed by excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.  

Atypical skin lesion 

Procedure Note: 

Benign appearing lesion #1 is located on left posterior knee. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.  

Atypical skin lesion 

Procedure Note: 

Benign appearing lesion #2 is right anterior lower leg. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.  

Atypical skin lesion 

Procedure Note: 

Lesion #3 is mid anterior chest. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.  


ASSESSMENT: 

173.9	    Basal cell carcinoma 
238.2	    Atypical skin lesion 
238.2	    Atypical skin lesion 
238.2	    Atypical skin lesion 

PLAN: 

 Basal cell carcinoma 

  Orders: 
     Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm  

 Atypical skin lesion 

  Orders: 
     Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm  
            A4550  Surgical trays (x1) 

 Atypical skin lesion 

  Orders: 
     Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm  

 Atypical skin lesion 

  Orders: 
     Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm  


CHARGE CAPTURE: 

Primary Diagnosis: 
173.9	    Basal cell carcinoma left anterior shoulder 

                   Orders:
                    99211-51  Office/outpatient visit; established patient, level 1  
                    11601  Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm  

238.2	    Atypical skin lesion posterior left knee 

                   Orders:
                    11401  Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm  
                              A4550  Surgical trays (x1) 

238.2	    Atypical skin lesion right anterior lower leg 

                   Orders:
                    11401  Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm  

238.2	    Atypical skin lesion anterior mid chest 

                   Orders:
                    11401  Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm  




The provider doesn't want to charge the level 1 office visit, but other than that how would you code the rest of it?

Thank you
Kristie Stokes, CPC-A


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## carolynnewberncpc (Jul 1, 2008)

I would not code the office visit because you don't have a documented chief complaint and it looks like the provider didn't treat or address any other problems except the lesions.  Be careful coding sep. E/M visits same day as procedures...be sure your documentation supports the charge and when it does, use modifier 25 on your sep. E/M code.

I would use 11601 X 1 with dx 173.6, 11401 X 3 with dx 238.9 if I coded from the record you presented.

I always wait for the path report and verify the size of the lesions and verify the type of lesion.  For instance, there is the dx of lipoma on the record above and if that was one of the lesions excised, its code would not be 238.9, it would be 214.x.

If your CPT 11401 had different dx's for these three lesions (like one was a lipoma and one was AK and one was nevus) I would code them with 11401 x 1 with dx 214.x, 11401-59 with dx 702.0, 11401-59 with dx 216.x.  Mod 59 tells the payer they are different lesions/sites but the procedure the provider used to remove them was the same.  Some payers want us to use modif 76 if they are different lesions on the same body site (even though it's really not a repeat procedure on the same lesion).  Don't use mod 51 unless you're doing multiple procedures through the same incision at the same session.

Clear as mud?


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## KristieStokesCPC (Jul 1, 2008)

I understand what you are saying and it makes perfect sense. Now my question is where do I apply the x1 or x2, etc? I'm not sure where it can go in our system to generate on the bill, unless the physician does an addendum to the note and I send it paper claim with the note? The payer is Tricare. Oh and we did receive the pathology report back before completing the size and type of lesions removed.

Thanks
Kristie Stokes, CPC-A


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## dmaec (Jul 1, 2008)

Kristie - in this case, you shouldn't apply a x1 or x2 anywhere.  (but in cases where you do, it would go in the "unit" box of the coding program or claim form). you wouldn't use modifier .51 on the office visit (if they were charging it) - it would be modifier .25 - "if" documentation supported an E/M with the procedures performed.
for the procedures,(from the information you gave) I would code as follows:
11601 link to dx 173.9
11401 link to dx 238.2
11401.59 link to dx 238.2
11401.59 link to dx 238.2

Donna


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## Lisa Bledsoe (Jul 2, 2008)

I agree with Donna.


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## KristieStokesCPC (Jul 2, 2008)

Thank you all very much  ..this helped alot! I feel blessed being a part of such a big family who helps each other out......

Kristie Stokes, CPC-A


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## FTessaBartels (Jul 2, 2008)

*Size of lesion plus margin*

The size of the lesion (plus margin) is taken BEFORE excision. Tissues can shrink before pathology gets to them.

The type of lesion - malignant or benign, etc - comes from the path report, so you would wait for the path report to finish your coding.

I would code each lesion on a separate line with -59 modifier on each line after the first one.

F Tessa Bartels, CPC-E/M


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