Dermatology Coding Alert

Append the right modifier for separate malignant lesion destructions

When your dermatologist performs destruction procedures on benign or pre-malignant lesions, you may find yourself jumping through hoops to collect payment if he also destroys malignant lesions during the same session.

The National Correct Coding Initiative's (NCCI) latest version (11.0), effective Jan. 1, bundles many malignant lesion destruction codes (17260-17286 range) into 17000 and 17004, so you'll need to be careful about reporting these codes together if you want to avoid denials.

Roll Malignant Location Codes Into 17000, 17004

Specifically, the new edits designate certain malignant lesion destruction codes that specify anatomic sites as column 2 ("mutually exclusive") codes.
 
Carriers that follow NCCI edits will bundle these codes into 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion) and 17004 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions), which are column 1 codes.
 
This means payers will only reimburse the lesser paid code unless steps are taken to override the edit, says Linda Martien, CPC, CPC-H, National Healthcare Review in Woodland Hills, Calif. Only those codes with a "1" in the modifier indicator column can be overridden, she says.
 
Tip: "Mutually exclusive" means that NCCI designates these two codes as highly unlikely to occur during the same procedure.

Note: To learn how to process all of the NCCI edits, read "Learn the 3 NCCI Rules and Throw Away Bundling Snafus".

Here's a column 1/column 2 breakdown of the lesion destruction bundles:

Column 1: Destruction, benign or premalignant lesion - 17000

Column 2: Destruction, malignant lesions on the trunk, arms, or legs - 17260-17264 (Destruction, malignant lesion [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], trunk, arms or legs; lesion diameter 0.5 cm or less ... through lesion diameter 3.1 to 4.0 cm)

Column 2: Destruction, malignant lesions on the scalp, neck, hands, feet, or genitalia - 17270-17273 (Destruction, malignant lesion [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], scalp, neck, hands, feet, genitalia; lesion  diameter 0.5 cm or less ... through lesion diameter 2.1 to 3.0 cm)

Column 2: Destruction, malignant lesions on the face, ears, eyelids, nose, lips, mucous membrane - 17280-17283 (Destruction, malignant lesion [e.g., lasersurgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less ...through lesion diameter 2.1 to 3.0 cm).

Column 1: Destruction, benign or premalignant lesion - 17004

Column 2: Destruction, malignant lesions on the trunk, arms, or legs - 17261-17262 (Destruction, malignant lesion [e.g., laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical curettement], trunk, arms or legs; lesion diameter 0.6 to 1.0 cm ...through lesion diameter 1.1 to 2.0 cm)

Column 2: Destruction, malignant lesions on the scalp, neck, hands, feet, or genitalia - 17276 (Destruction, malignant lesion [e.g., laser surgery,
electrosurgery, cryosurgery, chemosurgery, surgical curettement], scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm)

Column 2: Destruction, malignant lesions on the face, ears, eyelids, nose, lips, mucous membrane - 17281-17282 (Destruction, malignant lesion [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm ...through lesion diameter 1.1 to 2.0 cm); 17284 (...lesion diameter 3.1 to 4.0 cm); and 17286 (...lesion diameter over 4.0 cm).

To apply these bundles, take a look at the following example: An established patient comes to the dermatologist office so the dermatologist can remove a benign lesion on her right cheek. The dermatologist removes a 2-cm actinic keratosis with cryotherapy.
 
At the same time, the dermatologist decides to remove another lesion on the patient's arm that she has been watching for several months. She knows the lesion is malignant, so the dermatologist removes the 0.8-cm lesion with surgical curettement.
 
You should report these procedures with codes 17000 for the actinic keratosis destruction and then 17261 for the removal of the malignant lesion on her arm.
 
In order to notify your carrier that the dermatologist performed two distinct procedures at the same session, you would append modifier -59 (Distinct procedural service) to the second procedure (17261), Martien says.

Helpful: These bundles include a "1" modifier designation, which means you can append modifier -59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says William J. Conner, MD, physician at Meridian Medical Group, a multispecialty practice in Charlotte, N.C.

Don't miss: But make sure you have the documentation to distinguish the procedure as a distinct service the dermatologist completed or else risk facing denials, Conner says.

New Edits Affect G0345, Hundreds of Derm Codes

NCCI now bundles the new infusion code G0345 (Intravenous infusion, hydration; initial, up to one hour), and the codes for incision and drainage (10040-10180), excision (11000-11057), biopsy (11100), skin tag removal (11200), shaving of epidermal or dermal lesions (11300-11313), excision of benign lesions (11400-11471), excision of malignant lesions (11600-11646), nails (11719-11765), and virtually all of the remaining integumentary codes in the 10000 series.

Note: These codes have a "1" designation, which allows you to append -59 to the pair if the physician completes both procedures.
  
While infusion may not be a typical service performed in the dermatology setting, this is another example of the wide scope of impact that the NCCI version 11.0 edits have on the integumentary codes, Conner says.
 
Note: To view the latest update, refer to the CMS site www.cms.hhs.gov/physicians/cciedits/default.asp.