ED Coding and Reimbursement Alert

When applying codes 11300-11313 for shaving of epidermal or dermal lesions, you must follow a different set of rules than when you report more familiar lesion excision codes 11400-11646.

More fundamentally, you may not always be clear on when you should select 11300-11313 rather than the excision codes or, for that matter, a biopsy code. Here are the facts you need to identify and report shaving procedures properly.

To differentiate between shaving (11300-11313) and excision (11400-11646), you should first look at the removal's depth .

Technically, anytime the ED physician removes skin tissue, he's performing an "excision." For coding purposes, however, CPT narrowly defines an excision as involving "full-thickness (through the dermis) removal of a lesion." Shaving, by comparison, involves "sharp removal ... without a full-thickness dermal excision."

"Shaving implies a superficial removal," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

In some cases, the physician may remove the raised portion of a benign lesion and allow additional lesion tissue to persist in the dermis.

The ED physician's method to remove a lesion better reveals the difference between shaving and excision. During shaving, the physician uses a "transverse incision or horizontal slicing," as CPT says, to remove the lesion. That is, the physician holds the blade horizontal to the skin and moves it across the lesion, literally shaving it off.

Excision, in contrast, usually involves holding the blade perpendicular to (and thus cutting through) the skin to remove the lesion at a greater depth. In these cases, the physician always wishes to remove the entire lesion to the greatest necessary depth.

"Read the documentation carefully," Bishop says. "Physicians may use terms like -shave biopsy- for a procedure CPT might describe as an excision."

Bottom line: Pay more attention to the removal's depth than to the terminology your physician uses.

A final clue that may help you differentiate between shaving and excision is whether the surgical wound requires repair, Bishop says.

Although excision frequently requires suture or separate repair, shaving "does not require suture closure," CPT says. (For more information on coding lesion excision, see "Discover Pathology Before Choosing Excision Code" in ED Coding Alert, Vol. 11, No. 4 .)

When reporting shaving procedures, you must not consider the size of any margin the ED physician removes with the lesion. In fact, the physician may not document, or even take, a margin of tissue during a shave. This is a crucial difference from coding for excisions.

CPT groups shaving codes into three categories, as determined by the lesion's location:

- 11300-11303 -- trunk, arms, or legs

- 11305-11308 -- scalp, neck, hands, feet, or genitalia

- 11310-11313 -- face, ears, eyelids, nose, lips, or mucous membrane.

Within each category, CPT further divides the codes by the lesion's size. Thus, 11301 applies for a lesion of the trunk, arms or legs measuring 0.6 cm to 1.0 cm, whereas 11302 applies to a lesion in any of the same locations but measuring 1.1 cm to 2.0 cm (11303 would apply to lesions measuring more than 2.0 cm). Keep in mind that these measurements apply to the lesion's size only and do not include any margin.

The descriptors for 11300-11313 specify "single lesion," which means that you may report one code for each lesion that the physician removes by shave technique. If, for instance, the physician shaves 16 dermal lesions, you may report an appropriate code for each shaving. Keep in mind, however, that if the physician does shave an extraordinary number of lesions during a single session, you may have to submit documentation to explain the situation.

For example, the ED physician removes by shaving four dermal lesions: one on the left upper arm, measuring 1.0 cm, two on the chest, measuring 1.4 cm and 1.6 cm, and another on the neck, measuring 0.4 cm.

In this case, you would report 11301 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm) for the upper arm lesion, two units of 11302 (- lesion diameter 1.1 to 2.0 cm) to describe shaving of the chest lesions, and one unit of 11305 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less).

Bishop says that some payers might prefer that you list each removal as a separate line item, with modifier 59 (Distinct procedural service) appended to the second and subsequent identical codes. In the above example, this means you would report 11301, 11302, 11302-59, and 11305. Keep in mind that some payers may require modifier 51 (Multiple procedures), and apply a multiple procedural discount as well, on claims involving multi-lesion shaving.

"This is payer-specific, so ask for instructions if you-re unsure," Bishop says.

CPT guidelines, reiterated by the AMA in CPT Assistant (February 2008, Vol. 18, Issue 2), stipulate that removal of epidermal or dermal lesions using shave technique includes local anesthesia and, if necessary, chemical or electro cauterization to arrest bleeding. You should not attempt to code separately for these services.

Bishop says that the physician may choose freezing or chemical means to cauterize the wound, but as long as the physician doesn't place stitches or staples, the shave removal codes are still appropriate.

Although ED physicians may submit samples taken using a shave technique for pathological examination, the results of the exam (whether benign, malignant, or uncertain) have no bearing on your CPT coding (although obviously they matter tremendously for ICD-9 coding). Again, this is in contrast to excisions, which designate separate code ranges for benign and malignant lesions.

Perhaps more important, however, you must be careful not to confuse removal by shaving with biopsy only as 11100-11101 describe. CPT instructions preceding the biopsy codes specifically site "shave removals" as a method to obtain tissue for pathologic examination, which has added to the confusion over how to differentiate 11300-11313 from 11100-11101.

Physician intent matters most, says M. Trayser Dunaway, MD, FACS, CSP, author and educator with Healthcare Value in Camden, S.C. Often, a physician will remove by shaving a lesion that she suspects is benign. Although she may submit the tissue for biopsy, you should still select an appropriate shaving code rather than the biopsy code (biopsy is included in the shave).

But in the case of a suspected malignant lesion, the ED physician may use shaving to remove a portion of the tissue for examination, with the intent of removing the entire lesion by excision if pathology confirms malignancy. In such a case, you would apply the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and, if circumstances require, the appropriate lesion excision code (11600-11646) at a later session.

Even if the pathology report did not reveal malignancy in the above case, you would still report the biopsy code rather than a removal-by-shaving code. In this case, the intent was to obtain sample tissue for examination, not removal.