CODING CORNER: Don't Cut Your Corners With Lesion Excision Coding

Know all the facts before you choose a code
If you don't know the lesion's pathology, location and exact size, a mistaken removal code could cost your facility nearly $1,000 per service. Reading the pathology report carefully will help eliminate that risk -- but don't stop there.
Classify the Lesion -- But Not So Fast
Before you can code the excision, you have to know whether the lesion is benign or malignant. For benign procedures, you should choose a code from the 11400-11471 series. When the physician excises a malignant lesion, you should use the 11600-11646 series codes. Typically, the physician determines a benign or malignant state based on a pathology report.
"We wait for the pathology report before billing any lesion excision procedures," says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multi-specialty healthcare network in South Portland, Maine.
Warning: You could face denials or cost a patient his insurance coverage if you attempt to code a lesion excision without a pathology report, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.
Example: Suppose you don't have the pathology report, but you know the physician suspects that the lesion is malignant. Therefore, you report 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 or less), and link diagnosis code 172.5 (Malignant melanoma of skin; trunk, except scrotum) to the procedure. When the report comes in, you learn the lesion was benign.
In addition to incorrectly coding the procedure, you have classified the patient with a cancer diagnosis he doesn't have -- which could prevent him from obtaining insurance coverage in the future, Callaway says.
Pin the Code On the Anatomic Site
But don't stop with the pathology report. Once you've narrowed your coding selection to the 11400-11471 or 11600-11646 series, you have to know the lesion location to select the right code. You should review the physician's documentation to determine the anatomic site of the patient's lesion.
Helpful: CPT breaks down excision procedure codes into three body areas:
1. Trunk, arms or legs. When you find these areas in the documentation, make sure you report a code from either the 11400-11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs ...) or the 11600-11606 (Excision, malignant lesion including margins, trunk, arms, or legs ...) series.
2. Scalp, neck, hands, feet, genitalia. For a lesion on these body parts, use either 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere] ...) or 11620-11626 (Excision, malignant lesion including margins ...).
3. Face, ears, eyelids, [...]

- Published on 2004-07-09