ED Coding and Reimbursement Alert

Malignant lesion excisions reimburse at a higher rate than benign ones.

If you code lesion excision incorrectly, you could lose rightful reimbursement -- a minimum of about $33 per excision -- or you might accidentally mislabel a patient.

Encourage your physician to measure lesions before removing them, or more deserved money could fly out the door. Read on for some expert advice on how to prevent either problem from occurring on your excision claims.

The correct code for your physician's lesion removals depends on the lesion's pathology. So experts strongly recommend that you wait until you have the pathology report before choosing an excision code.

But what happens when the pathology report is nowhere to be found? If you do not have access to the pathology report (common for EDs), let your physician make the final decision on whether a lesion is benign or malignant.

(For more information on choosing the correct CPT code for lesion removal, see "Know Size, Area of Lesion Before Choosing Code" on page 19.)

Bottom line: Removal of a benign lesion of 0.5 cm or less from a patient's trunk, arms, or legs (11400) pays about $67 (1.86 transitioned facility relative value units [RVUs] multiplied by the 2009 Fee Schedule conversion rate of 36.0666). Removal of a malignant lesion of the same size and location (11600) pays about $100 (2.79 RVUs multiplied by 36.0666).

More urgently, coding for malignant removal when the lesion is benign could land you in hot water, said Cristina Bentin, CPC-H, CCS-P, CMA, during her integumentary coding session at The Coding Institute's National Coding and Reimbursement Conference in Orlando, Fla. (www.codinginstitute.com). Once a patient receives a diagnosis from a physician, it is very difficult to have the diagnosis reversed -- even if it is incorrect, relays Bentin.

In a nutshell: "If you send a bill with a definitive diagnosis that is wrong, you have potentially mislabeled that patient forever," said John Bishop, PA-C, CPC, at the Orlando conference's "Lesions, Lumps, Bumps, and Flaps" session.

Giving a patient cancer when she does not have it can greatly affect her future access to healthcare services, and could land your ED in legal trouble.

When determining lesion size, the physician should add together the diameter of the lesion plus the size of the margins. For optimal reimbursement, the physician should perform this measurement before removing the lesion.

For example, a physician excises a back lesion with a diameter of 1.5 cm, along with margins of 0.5 cm on each side. The pathology report states the tissue is benign. To get the correct CPT code, add the excised diameter (1.5 cm) and margins (0.5 cm + 0.5 cm) to arrive at 2.5 cm.

In this scenario, you should report 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter 2.1 to 3.0 cm) for the excision.

Coders may need to remind physicians that they should measure the lesions and margins, said Bentin, founder of Coding Compliance Management in Baton Rouge, La.

Bottom line: "You are losing money if you don't measure the lesion before cutting it out; when you cut something out, it usually shrinks," explained Bishop, president of Bishop and Associates in Tampa, Fla. The sample will shrink further when the physician puts it into a preservative for shipping to pathology. So if you measure the lesion post-pathology, it will be smaller than it would have been pre-removal.

Consider the above example. The average pay for 11403 is about $126 (3.5 RVUs x 36.0666) If the physician did not include the margins, you would have to report 11402 ( - excised diameter 1.1 to 2.0 cm), which pays about $99 (2.75 RVUs x 36.0666) -- for exactly the same service.

Best bet: Remind physicians to measure and document the lesion's size pre-removal, and show them the differences in reimbursement for different-sized lesions. If the physicians continue to measure lesions after removal, the practice will continue to lose money, according to Bishop.