Dermatology Coding Alert

For radical resections, your dermatologist's documentation must specify this vital detail.

Suppose your dermatologist treats a soft tissue lesion of the back. Currently, you may turn to the integumentary section of your CPT book -- but for 2010, you'll look at new 2xxxx codes specifying size and "subcutaneous" versus "subfascial." That may mean greater specificity for you and your payers, but unless your dermatologist documents this information, you'll be stuck reporting lesser codes -- and reaping lesser reimbursement.

Here's the good news: Expanding your excision and radial resection options means that you're less likely to make coding mistakes. Examine these new dermatology CPT entries and start using them Jan. 1.

Cut to the Excision Code Change Chase

When your dermatologist treats a patient with a really deep facial tumor, you've been stuck using 11440-11446 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane ...), which are for "more for superficial lesions," explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions.

As of Jan. 1, you will have four new tumor excision codes to add to your arsenal. They are:

• 21011 -- Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm

• 21012 -- ... 2 cm or greater

• 21013 -- Excision, tumor, soft tissue of face and scalp, subfascial (e.g., subgaleal, intramuscular); less than 2 cm

• 21014 -- ... 2 cm or greater.

Difference: The new codes are "for much deeper, more complex lesions," Cobuzzi says -- hence referencing tumors. Also, up until 2010, "we have had deeper tumor excision codes for the neck, but they have not been available for the face and scalp.

This will no longer be the case." "Until these codes, there has never been a way to express the depth of removing a tumor or tumorous mass of the face or scalp except with modifier 22 (Unusual procedural services) added to 1144x," says Leslie Johnson, CPC, quality control auditor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net.

Expand This Example to All Excision Additions/Revisions

The excision changes don't stop there. You'll find similar new code additions and revisions specifying size and subcutaneous/subfascial:

• 21552-21556 -- Excision, tumor, soft tissue of neck or anterior thorax ...

• 21930-21933 -- Excision, tumor, soft tissue of back or flank ...

• 22900-22903 -- Excision, tumor, soft tissue of abdominal wall ...

• 23071-23076 -- Excision, tumor, soft tissue of shoulder area ...

• 24071-24076 -- Excision, tumor, soft tissue of upper arm or elbow area ...

• 25071-25075 -- Excision, tumor, soft tissue of forearm and/or wrist area ...

• 27043-27048 -- Excision, tumor, soft tissue of pelvis and hip area ...

• 27337-27339 -- Excision, tumor, soft tissue of thigh or knee area ...

• 27618-27619 -- Excision, tumor, soft tissue of leg or ankle area ...

• 28039-28045 -- Excision, tumor, soft tissue of foot or toe.

Note: In most cases, these codes specify less than 3 cm or 3 cm or greater. Exceptions: The "subfascial" codes for the neck or anterior thorax (21554, 21556), back or flank (21932, 21933), abdominal wall (22900, 22901), shoulder (23073, 23076), and upper arm or elbow (24073, 24076) specify less than 5 cm or 5 cm or greater. Also,the excision codes for the foot or toe specify less than 1.5 cm or 1.5 cm or greater.

Notice the specification of "subcutaneous" versus "subfascial." Your physicians must document this information so that you can choose the appropriate code. "Fascia can be a very important word," says Pam Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.

Also, keep in mind that "the descriptors don't say 'malignant,' which means you're not compelled to have a malignant neoplasm when your note specifies 'tumor,'" Cobuzzi says.

Don't forget: In addition, you also have the following excision of tumor or vascular malformation codes:

• *26111 -- Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater

• *26113 -- Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (e.g., intramuscular); 1.5 cm or greater

• 26115 -- Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm

• 26116 -- Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (e.g., intramuscular); less than 1.5 cm

*These are new codes. The other two are merely revised.

Ramp Up to These Radical Resection Changes

CPT altered the above excision codes to specify size -- and the same goes for radical resection of soft tissue codes. For instance, the descriptor for 21015 now states (emphasis added) "Radical resection of tumor (e.g.,malignant neoplasm), soft tissue of face or scalp; less than 2 cm." You can also add new code 21016 (... 2 cm or greater) to your radical resection arsenal.

Example: Your dermatologist performs a radical resection of a tumor present on the patient's face. He documents, "The tumor measures approximately 3 cm in size." In this instance, you would report new code 21016.

Beware: "The term 'radical resection' makes me nervous," Biffle says. "Your dermatologist has to specify he went beyond the fascia" in order to report this code. Check out these other new/revised radical resection codes:

• 21557-21558 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or anterior thorax ...

• 21935-21936  -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or flank ...

• 22904-22905 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of abdominal wall ...

• 23077-23078 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of shoulder area ...

• 24077-24079 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of upper arm or elbow area ...

• 26117-26118 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of hand or finger ...

• 27059 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of pelvic and hip area; 5 cm or greater

• 27364 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or knee area; 5 cm or greater

• 27615-27616- --  Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or ankle area ...

• 28046-28047 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot or toe ...

Heads up: Be sure to check these codes for size which varies from 2 cm in the case of the face and scalp (21015-21016) to 3 cm in the case of the hand and finger (26117-26118). You'll also see 5 cm, such as in the case of the neck or anterior thorax (21557-21558).

Note the Unusual 14000 Series Alterations

The integumentary codes are usually immune to CPT changes, but not so for CPT 2010.

First of all, cross out 14300 (Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area). CPT 2010 deletes this code. "The 'unusual or complicated' terminology no longer appears," Biffle says. "If the tissue is that big, then it is unusual or complicated."

In its place, CPT added new codes 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) and add-on code +14302 (Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof [List separately in addition to code for primary procedure]). "It's interesting they added this delineation," Cobuzzi says. Sometimes scar excisions are so severe that a physician must use an adjacent tissue transfer to close the wound. These codes describe the tissue size.