Dermatology Coding Alert

Question: Our physician removed and destroyed multiple lesions on a Medicare patient during the same visit. We want to code it 11200, 11201, 11201-59, 17000 and 17003, but we have had trouble in the past getting reimbursed for these multiple procedures. Do we need other modifiers, or are these procedures bundled?

Wisconsin Subscriber

Answer: According to the National Correct Coding Initiative (NCCI), 11200 (Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions) and 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) are mutually exclusive procedures, with 17000 being the comprehensive code and 11200 bundled as a component code.
 
However, assuming that in your case these two procedures were performed for different lesions, billing the two sets of procedures together with modifier -59 (Distinct procedural service) attached to the lower-valued code is appropriate.
 
Your scenario also deals with CPT add-on codes. Two of the codes in your scenario, +11201 (... each additional 10 lesions [list separately in addition to code for primary procedure]) and +17003 (... second through 14 lesions, each [list separately in addition to code for first lesion]), are add-on codes, which are identified in CPT by a "+" sign in front of the code.
 
According to the instructional notes in CPT, add-on codes describe additional intraservice work associated with the primary procedure, e.g., additional lesion(s). Add-on codes can never stand alone; they are always secondary procedures and must be billed in addition to the primary procedure code. Because they are always secondary procedures, the multiple-surgery reduction has been calculated into the relative value units (RVUs) assigned; therefore, never use modifier -51 (Multiple procedures) with an add-on code.
 
There are other important guidelines for the codes in your scenario. Your question does not indicate how many lesions were destroyed or how many skin tags were excised, but the number of lesions is important for coding. To use 11200 and 11201 together, you must have excised at least 25 skin tags.
 
Code 11201 states, "each additional 10 lesions." If, however, you excise fewer than 10 additional lesions beyond the first 15, use modifier -52 (Reduced services) with 11201.

For example, if you excised 22 skin tags, report 11200 for the first 15 and 11201-52 for the remaining seven. Modifier -52 indicates that the entire number of lesions, 10, specified in the code description was not excised.
 
On the other hand, 17003 is reported once for each additional lesion destroyed. Therefore, if three lesions were destroyed, you should report 17000 once and 17003 twice.
 
You should use 17003 in this manner until you reach a total of 15 or more lesions.
 
If 15 or more lesions were destroyed, report 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) only once.
 
In the case above, you should code 11200, 11201, 17000-59-51 and 17003-59. In this coding scenario, 25 skin tags were excised, and two skin lesions were destroyed by any method.