ED Coding and Reimbursement Alert

Your ED physician removes a pair of benign lesions from the patient's left thigh; you add the repair lengths and code based on those numbers. You've coded correctly ... right?

Wrong: Many coders get tripped up by lesion removal codes, which are governed by different rules than lesion excision codes. Get the real lowdown on coding multiple lesion excisions right here, and you'll get it right every time.

When your physician removes multiple lesions, "code for each individual lesion; this is not like laceration repairs, where you combine the length of all of the same body area/complexity wounds," explains Sharon Richardson, RN, compliance officer at Emergency Groups' Office in Arcadia, Calif.

"Report separately each benign [or malignant] lesion excised," reads the CPT 2010 guidelines preceding each lesion excision section: Depending on the nature and location of the lesions, however, you may need to employ modifiers on multiple lesion removals.

Example: A patient presents with one lesion on his forehead and one on his neck. The patient cannot stop scratching them, which is causing bleeding. The ED physician performs an expanded problem focused history and physical exam. During the history portion of the E/M,the patient reports that he has no access to a dermatologist, so the ED physician chooses to excise the lesions.

The physician performs a pair of simple benign lesion excisions: a 1.3 cm lesion from the patient's face and a 1.8 cm lesion from the patient's neck. The physician then writes a five-day antibiotic prescription and a 10-day prescription for Tylenol #3.

On this claim, Richardson recommends reporting the following codes:

• 11422 (Excision, benign lesion including margins,except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) forthe neck lesion removal

• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) for the facial lesion removal • modifier 59 (Distinct procedural service) appended to 11442 to indicate the separate nature of the removals -- if the insurer requires it**

• 99283 (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 moderate complexity ...) for the E/M service

• 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 99283 to show that the E/M and lesionremovals were separate services

**Alternate scenario: If the patient in the above example had both lesions removed from his face, you could report 11442 and 11442-59 for the repairs.

If the lesions are in different anatomic areas -- or if the lesions differ in pathology -- the payer might want you to code the removals separately without any modifiers. Other payer peculiarities might include wanting  o see modifier 51 (Multiple procedures) on multiple lesion removal claims.

Best bet: Check with the carrier before coding multiple lesion removals, as there can be some coding differences among insurers for these services.