ED Coding and Reimbursement Alert

Lesion excision coding can be a breeze if you follow the proper steps toward selecting a code. But if you stumble on one of those steps, your code choice stands a good chance of being inaccurate.

No worries: Check out this three-step guide to choosing the proper lesion excision code each time.

When reporting lesion excision, you should choose from 11400-11446 for benign lesions and 11600-11646 for malignant lesions, says Eli Berg, MD, FACEP, chief executive officer of Medical Reimbursement Systems Inc., an ED billing company in Woburn, Mass.

Discovering the lesion type can be especially difficult in the ED, Berg says.

Good news: Most ED lesion removals are benign.

Bad news: "In the ED the physician will not have the benefit of frozen section pathology, and the coder may not have full access to the pathology report, Berg says. In an ideal world, you would base the coding on the final pathology report.

But if you have no access to the pathology report, you must rely on the physician's documentation and diagnosis. "Terms such as -cystic lesion- or -skin lesion- will typically represent a benign lesion," Berg says.

Best bet: Let the physician make the final decision on lesion pathology. The coder should never, under any circumstances, decide the pathology of a lesion from the operative notes.

"A coder would not want to tag a patient with a malignant diagnosis without definitive proof," says Linda Martien, CPC, CPC-H, secretary of the AAPC National Advisory Board and coding specialist at the National Healing Corp. in Boca Raton, Fla.

Possible consequences: In addition to the embarrassment it might cause your ED, a false cancer diagnosis could also open the practice up to legal trouble.

Best bet: Use the malignant code set only when the physician specifies the lesion as malignant, Berg says.

Once you have determined lesion type, you need to locate the body area where the physician excised the lesion. For coding purposes, CPT breaks lesion excision codes into four body areas, according to Yvonne P. Mayer, CPC, senior coding analyst at One Park Fletcher in Indianapolis:

- trunk, arms, legs (11400-11406 for benign lesions, 11600-11606 for malignant)

- scalp, neck, hands, feet, genitalia (11420-11426, 11620-11626)

- face, ears, eyelids, nose, lips, mucous membrane (11440-11446).

- face, ears, eyelids, nose, lips (11640-11646).

So if encounter notes indicate that the ED physician excised a benign lesion from a patient's left thigh, you-d choose a code from the 11400-11406 family.

Next, you-ll need to measure the total excision area of the lesion, because your code choice will depend on the size of the excision.

Do this: Measure the greatest clinical diameter of the lesion, plus the margins required to completely excise the lesion, Berg says.

"It is the provider's responsibility to measure the lesion with margins prior to excision of the lesion. Typically, providers will list the measurements as one unit, which includes both the lesion and margin sizes together," Mayer says.

Example: The ED physician excises a benign lesion from a patient's scalp. The greatest clinical diameter of the lesion is 2.2 cm, and the procedure required margins of 0.3 cm on each side.

In this instance, the total excision area is 2.8 cm (2.2 + 0.3 + 0.3), and your code choice is 11423 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm).