Dermatology Coding Alert

For benign lesions, numbers -- not size -- matters.

Having a hard time reporting milia treatments? Part of the challenge is discerning between acne surgery codes and destruction codes. Keep these four clues in mind and you'll avoid causing your ractice big headaches on possible denials.

The main difference between 10040 (Acne surgery -- e.g., marsupialization, opening or removal of multiple milia, comedones, cysts and pustules) and 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) is that the 17110 code is a destruction while the 10040 code is a removal.

"Code choices should be fairly simple by definition alone. The code 10040 states that an incision is made into the cyst or milia for removal and code 17110 is for destruction," says Christie Thomas, CPC, PCS, resident coder of Mercy Physicians Group in Fort Scott, Kansas.

Hint: In CPT, any code with a prefix of "17" is a destruction code. As mentioned in 17110's description, the most common forms of destruction include the application of liquid nitrogen or other chemical agent (a.k.a. cryosurgery), curettage, electrodessication, or the use of a laser.

Meanwhile, your dermatologist usually removes a milia by using a comedone extractor, which is a tool not much bigger than a pair of tweezers.

Cost: Don't get tempted to report one code over the other just because of potential payback figures. Based on Medicare rates, the reimbursement advantage of 10040 versus 17110 is notable. Code 10040 pays back $83.72 while 17110 comes in at $63.87. Also, you should always be aware that some payors may not consider treatment of milia as a medically necessary procedure.

The series 17110-17111 specifies the destruction of benign lesions that is medically necessary. If you'd use a destruction code to report milia treatment, you should remember that "17110 is for up to 14 lesions while 17111 (...15 or more lesions) is for 15 or more lesions treated at one time," Thomas notes. Thus, you will never code 17110 and 17111 together at any given time on any particular patient.

Red flag: When assigning codes for benign or premalignant lesions, the number of lesions matters.Furthermore, an appropriate ICD-9 code should come with reporting 17110-17111. Some of the most common include 702.11 (Inflamed seborrheic keratosis) 078.10 (Viral warts, unspecified), 706.2 (Sebaceous cyst), and 078.19 (Other specified viral warts [e.g., common wart, flat wart, verruca plantaris]), to which group milia belongs.

Extra: Dermatologists may also report 17110-17111 with 216.x (Benign neoplasm of skin) and 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin).

I&D stands for "incision and drainage" and usually pertains to the removal of a foreign body in the skin and subcutaneous tissue (including nails). It is a common treatment for an abscess in which a scalpel or needle is inserted into the skin overlying the pus and the pus is drained. When treating milia this way, 10040 applies. While most insurance carriers may deny a claim for 10040, submitted with a diagnosis of simple acne, they will usually pay for a diagnosis of symptomatic milia for removal (706.2, Sebaceous cyst). The reason is that they consider 706.2 as medically necessary. A good example of symptomatic milia would be an inflamed milia on the nasal bridge irritated by eyeglasses. Remember: You should never code what payers will pay; you must code based on your physician's documentation.

Caution: You should be wary of 10040's sub-classifications for simple versus complicated. CPT has no definite answer in distinguishing simple over complicated. That's up to you. For instance, for an I&D procedure like 10040, a complicated case may involve the use of drains or packing, as opposed to a simple incision into the abscess itself, with no requirement for further intervention. Be clear in documenting why a particular scenario requires more extensive work (hence complicated) than is usually needed. On the other hand, a simple I&D procedure involves "an incision of an abscess, cyst, carbuncle, suppurative idradenitis, furuncle, or paronychia that is situated just below the skin's surface or subcutaneously," explains Yvonne P Mayer, CPC, senior coding analyst at Bill Dunbar and Associates LLC in Indianapolis.

Milias are tiny white bumps of keratin in the glands of the skin. They are common in newborns' faces -- usually on the tip of the nose or chin -- but are also found in adults. Medicare and most carriers have a benign lesion destruction/removal policy that you must meet in order to bill milia treatment. Look out for the proper symptoms that should be indicated in your dermatologist's pathology report, such as:

• inflammation

• bleeding

• clinical suspicion for malignancy

• pain

• irritation (various carriers differ on policies for this symptom).

In case of recurring: When your dermatologist treats a previously treated lesion, you would use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) for treatment of lesions occurring during the 10-day postoperative period. No modifier is needed after the 10-day postoperative period expires.