Dermatology Coding Alert

Tips: Size – and the number of lesions – matter.

Lesion excisions – including warts and malignant or premalignant lesions – are in many ways a dermatology practice’s bread and butter. But before you dig in to lesion shaving, removal, and destruction coding, be sure you’re not falling prey to one of these common myths.

Myth: There is no real difference between shaves and excisions.

Reality: There are many differences, in the complexity of the procedures and the reimbursement they bring.

Thickness matters: To distinguish between shaving and excision, one useful piece of data is the thickness of the skin that the dermatologist removed. The shaving CPT^® codes, 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…) describe removal of the lesion down to the middle dermis, without disturbing the subcutaneous tissue.

The excision CPT^® codes, 11400-11646, describe full-thickness removal of the lesion that can extend into subcutaneous tissue, says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas.

Note the method: During shaving, the dermatologist uses a horizontal slicing motion to remove the lesion. The dermatologist holds the blade horizontal to the skin and moves it across the lesion, literally shaving it off. There is usually no need for suture closure or a repair code.

Excision, however, usually involves holding the blade perpendicular to (and thus cutting through) the skin with an elliptical, wedge, or circular incision to remove the lesion at a greater depth – for which a scalpel is better suited. In these cases, the surgeon always wishes to remove the entire lesion to the greatest necessary depth. Excisions may require surgical closure.

Payment reflects difficulty: The CPT^® code for shaving of a single lesion from the trunk less than 0.5 cm in diameter, 11300 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less), is approximately $98.10 in a non-facility setting (2.74 relative value units multiplied by the 35.8043 conversion factor).

By contrast, the CPT^® code for excision of a lesion of similar size and location, 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) is $125.32 (3.50 RVUs), showing that Medicare values the work that goes into excision more than shaving.

Biopsies matter – sometimes: Whether or not sending a sample to pathology will affect your CPT^® code choice depends on the dermatologist’s intent. Often, a dermatologist may shave a lesion he suspects to be benign and submit the tissue for biopsy. But in that case, you should still submit the appropriate shaving code instead of the biopsy code, because biopsy is included in the shave.

If the dermatologist suspects a malignant lesion, he may shave off part of the wart to send to pathology, intending to excise the entire lesion if pathology to confirm that the tissue is malignant. Here, you would apply the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and, if required at a later session, the appropriate code for excision of malignant lesion procedure (11600-11646).

But even if the pathology report did not reveal malignancy in the above case, you would still report the biopsy code rather than a code for removal by shaving. In this case, the intent was to obtain sample tissue for examination, not removal.

Myth: You can code benign wart destruction per lesion.

Reality: No, if the dermatologist destroys between one and 14 benign lesions, one unit of CPT^® code 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) is the appropriate claim.

For 15 or more lesions, the proper code would be one unit of CPT^® code 17111 (…15 or more lesions).

That’s true even if you destroy warts from multiple sites, say experts. The code descriptors specify the total number of lesions removed, but don’t specify anatomical site. So your count can include warts from multiple areas.

Don’t miss: You also can’t report CPT^® codes 17110 and 17111 together. If the dermatologist destroys a total of 14 or fewer warts, report 17110; if he destroys a total of 15 or more, report 17111.

Myth: Premalignant and benign are interchangeable.

Reality: No, a benign lesion is self-contained and does not have the potential to spread to other parts of the body. A premalignant lesion, while not yet malignant, is by no means benign. A premalignant, or precancerous, lesion has the potential to spread to other areas, but its growth has not yet become uncontrolled.

As a result, you should not use the benign lesion destruction codes (17110-17111), which would be appropriate for wart removals, with CPT^® codes 17000-17004 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses] …). These codes are strictly applicable to premalignant lesions, and warts do not fall into that category.