ED Coding and Reimbursement Alert

Coders unwilling to delve into excision encounter notes to search for details could fail to unearth ethical reimbursement for their physicians' services.

The $kinny: The ED physician removes a benign lesion from a patient's upper right arm. You code for a 1.0 cm removal, but neglect to include the surgical margins, which upped the excision total to 2.2 cm. Undercoding in this instance can cost your ED about $50.

Avoid lesion removal mistakes with this expert input on optimal excision coding:

You will frequently choose from the following code sets when a physician removes a lesion, confirms Sharon Richardson, RN, compliance officer at Emergency Groups' Office in Arcadia, Calif.:

• 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) to 11446 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm) for benign lesions, or

• 11600 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less) to 11646 (Excision, malignant lesion including margins, face, ears eyelids, nose, lips; excised diameter over 4.0 cm) for any malignant lesions.

Remember: "These codes refer specifically to excision of lesions and do not include removal of skin tags, paring of calluses, or shaving of lesions, or removal by other means than excision," reminds Linda Martien, CPC, CPC-H, CPC-I, secretary for the American Academy of Professional Coders' (AAPC) national advisory board.

While your ED physician could remove a malignant lesion, you need proof of malignancy before you can choose a code from 11600-11646, says Richardson. "The only way to be sure that a lesion is malignant is to wait for a path report," she explains.

As waiting for the report is no problem for other physician offices, "ED charts are usually sent for billing within a day or two of the visit," says Richardson. This means that the ED coder will typically use the benign lesion codes without waiting on pathology.

Example: After performing a level-two ED E/M service, the ED physician removes a 0.7 cm lesion (including margin) from a patient's left arm. The pathology report does not come in before the bill drop date, so the coder defaults to the benign codes and reports the following for the encounter:

• 11401 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.6 cm to 1.0 cm) for removal of the lesion

• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and the removal were separate services

• 216.6 (Benign neoplasm of skin; skin of upper limb,including shoulder) appended to 99282 and 11401 represent the lesion.

Remember to include margins the ED physician took to remove the lesion when totaling measurement length: If you code lesion excisions based strictly on the lesion's size, you're cutting deserved money out of the claim.

Do this: Measure each excision "at the widest diameter, including any margins," explains John F.Bishop, PA-C, CPC, CGSC, CPRC, president of Bishop & Associates, Inc. in Tampa.

Remember, a couple tenths of a centimeter can cost you half a hundred bucks.

Example: The ED physician removes a benign lesion from a patient's scalp; the lesion size, including margins,is 1.1 cm. The coder only counts lesion size, however, so she reports 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) when she should have reported 11422 (... excised diameter 1.1 to 2.0 cm).

Fallout: The 11420 code pays about $75 (2.10 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846).

Conversely, 11422 brings in about $124 (3.43 RVUs multiplied by 36.0846).

Further, if your ED does happen to wait on pathology before sending a lesion removal claim, be sure to measure lesion size pre-excision.

"Do not report [lesion and margin] size from the pathology report," warns Cheryl Starner, revenue integrity analyst for Missouri's Truman Medical Centers. The sample you send to pathology will inevitably differ in size from the one you get back, she says.