Dermatology Coding Alert

Follow 3 steps to find the right code for these 3 integumentary procedures.

A patient presents with several skin lesions, and the dermatologist treats them. But as a dermatology coder , you know coding these procedures is far from simple. You need to determine whether your dermatologist performed a biopsy or destruction. These three steps from our experts will make your job easier.:

Step 1: Look at Lesion Method

To distinguish between procedure codes 11100-11101, 17000-17004, and 17110-17111, you should first check your dermatologist's notes for the method he used.

Key words: Examine the note to determine whether the physician biopsied or destroyed the lesion. Lesion biopsy indicates the dermatologist performed 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) or +11101 (... each separate/additional lesion [List separately in addition to code for primary procedure]). If he destroyed the lesion, you should code a destruction, such as 17000-17004 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses] ...) or 17110-17111 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions ...).

Sometimes, however, dermatologists don't include the procedure information in the chart note.

You may have to let the lesion method drive your biopsy-versus-destruction coding. In this case, knowing which method corresponds to which procedure will clue you in to the proper code.

Watch for: Medicare may deny 17000 with any diagnosis except 702.0 (Actinic keratosis), for medical necessity, warn experts. But don't confuse actinic keratoses (AK) with seborrheic keratoses (702.11, Inflamed seborrheic keratosis; and 702.19, Other seborrheic kertatosis), a non-cancerous skin growth. Unlike AK, Medicare does not always cover a dermatologist's removal of a seborrheic keratosis (SK). ICD-9 code 702.11 indicates medical necessity, says Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. CMS usually considers the removal cosmetic unless the growth is bleeding, painful, intensely itchy, purulent or impairs the patient's function in some other way.

CPT's destruction notes indicate you may report 17000-17004 and 17110-17111 for any method of destruction.

Bill a destruction code when the dermatologist destroys an entire lesion using these methods:

• electrosurgery
• cryosurgery
• laser and chemical treatment
• surgical curettement.

Hint: If your dermatologist's notes state "LN2," you should report a destruction code. The symbol stands for liquid nitrogen, which a physician uses in cryosurgery to freeze a wart.

On the other hand, 11100 refers to obtaining tissue. The dermatologist may biopsy the lesion by:

• shaving
• any sharp instrument, such as a punch tool or knife.

Problem: Notes that include contradictory phrases, such as "destroyed wart and sent for biopsy," may leave you still guessing which code set to choose. Encourage your physician to reserve the term "biopsy" to refer to the procedure, experts advise.

Alternative: If you don't have access to the dermatologist, delve further into the chart note with the next step.

Step 2: Check Procedure's Purpose

If you can figure out why the dermatologist performed the lesion procedure, you'll have a better idea of whether you should code a biopsy (11100) or destruction (17000-17004, 17110-17111). A physician biopsies or destroys a lesion for different reasons.

Biopsy determines diagnosis: In 11100, the dermatologist wants to obtain a diagnosis. A biopsy involves taking a piece of a neoplasm or abnormality to examine the specimen microscopically. The dermatologist wants to know whether the lesion is cancerous or benign. Therefore, he will always send the specimen to pathology.

Destruction eliminates lesion: The 17000 codes, however, rarely involve sampling. The dermatologist is instead destroying the lesion, and is not concerned with the lesion's diagnosis. The physician usually already knows the lesion's type. In fact, he may have previously biopsied the lesion (11100).

Step 3: Differentiate Diagnosis

Although the above two steps should narrow your code selection to biopsy or destruction, you need to know the lesion's type to choose between 17000-17004 and 17110-17111.

CPT® differentiates codes 17000-17004 and 17110-17111 based on diagnosis.

If the dermatologist destroys a premalignant lesion, such as actinic keratoses (702.0), you should report 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses]; first lesion]).

Use +17003 (... second through 14 lesions, each [List separately in addition to code for first lesion]) as an add-on code to represent each additional lesion destruction up to 14 units. For destroying over 14 such lesions, report only 17004 (... 15 or more lesions).

You should use 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) when the dermatologist destroys up to 14 flat warts (078.10, Viral warts, unspecified), molluscum contagiosum (078.0) or milium (white head) (706.1). Assign 17111 (... 15 or more lesions) for destruction of more than 14 lesions. This code series is for all destruction except actinic keratoses, skin tags, and malignancies.