Coding Corner: Measure Carefully When Coding Lesion Removal

Less than a centimeter equals more than $200

You know the lesion's measurement, whether it's benign or malignant, and the number of lesions removed - but the correct information won't matter unless you know how to apply it. Put the facts you've gathered into action with these expert tips on modifiers, pathology reports, and layered closures.

Count Every Millimeter
All the codes for lesion removal are size-based: Which code you choose and which APC it maps to depend on the measurement of the lesion. As of January 2003, the protocol for scaling lesions includes the "margins" - normal tissue surrounding the lesion that gets excised to ensure the removal of the entire lesion. Make sure the surgeon has not simply counted the lesion diameter, because a 0.1-centimeter mistake could translate into considerably more or less payment.
For example, code 11644 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm) maps to APC 0021, but 11646 (... excised diameter over 4.0 cm) - which could only differ by a fraction of a centimeter - maps to APC 0022. The reimbursement jump is almost $200.
Calculate the lesion's diameter at its widest point, and calculate the width of the margin at the lesion's narrowest point, says Marcella Bucknam, CPC, CPC-H, health information management coordinator at Clarkson College in Omaha, Neb. For instance, if the lesion is 1.5 cm and the surgeon allows an additional 1.5 cm on each side in order to remove all malignancy, you'll use the code appropriate for a 4.5-cm diameter.
Use the "Before" Picture When Possible
Don't wait for the pathology report for your information about the lesion's size, Bucknam says, unless no other source is available. "Once the surgeon cuts the tissue out, [the lesion] loses its tension and gets smaller," she says. "And once it's sent in formalin to the pathology department, it shrinks even further." So, if you wait for the path report to code the removal, the lesions will be much smaller, and you'll be kissing well-deserved payment goodbye. "The lesion and margin size before the excision is what you want to use," Bucknam says.
In some cases, though, you won't have enough info to code prior to receiving the report. "If the surgeon doesn't tell you how big the lesion is, or how big the margins are, or tells you the size of the lesion but not the margins, you have no choice but to rely on the path report," Bucknam says. Even if you know that the lesion shrank, you cannot code for removal of a larger lesion without documentation.
Timing also runs the coding show [...]

- Published on 2003-10-08