ED Coding and Reimbursement Alert

Complicated repairs require additional coding.

So you've got a procedure note in front of you indicating multiple lesion removals from the same patient during the same session.

What to do? Combine repair lengths? Code each removal separately?

It depends. Check out this in-depth inside information from experts who know how to deal with all types of multi-lesion removals your ED's likely to see.

Code Each Simple Removal Separately

You'll typically code each lesion removal separately regardless of pathology or anatomical location. Usually, "you would code for each individual lesion; this is not like laceration repairs where you combine the length of all of the same body area, or complexity, wounds," relays Sharon Richardson, RN, compliance officer with Emergency Groups' Office in Arcadia, Calif.

Example: A patient presents to the ED with a lesion on his forehead and one on his neck, the patient reports that the lesions "itch bad," and he says he cannot stop scratching them. The physician performs an expanded problem focused history and physical exam and, as the patient has no access to a dermatologist, the physician performs simple excision on the lesions; total excision area for the forehead lesion is 1.4 cm, and total area for the neck is 1.6 cm with simple repair.

The physician writes "tissue benign" in the notes, and writes the patient a prescription for antibiotics and painkillers. Notes indicate moderate medical decision making. On this claim, you'd report the following:

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)

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) modifier, 51 (Multiple procedures) appended to 11422 to show that the removals were separate services

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

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 the lesion removals were separate services.

Modifier alert: If you are unsure of your insurer's preference on modifiers in these instances, be sure to contact a representative before filing a multi-lesion removal claim. Insurers most commonly accept modifier 51 for these scenarios, but individual payer policy may vary; some might prefer modifier 59 (Distinct procedural service).

Add Lengths for Defect Repairs

In some instances, the ED physician has to repair the lesion removal area via intermediate or complex repair. When this occurs, you'll do the following

• Code each lesion removal separately
• Apply the laceration reporting rules, including adding the length of similar complexity and anatomically related areas.

Explanation: For simple lesion removals, simple repairs are bundled into the codes. If the repair is intermediate or complex, it is separately reportable says Cheryl Starner, CPC, revenue integrity analyst for Missouri's Truman Medical Centers. Consider this example from Richardson:

Example: The ED physician removes lesions from a patient's nose and upper lip area; total removal area for the nose lesion is 0.4 cm and total area for the lip lesion is 3.2 cm. In order to minimize scarring, the physician performs significant undermining of the surgical sites, using subcutaneous sutures to take tension off of the wounds and documents a complex closure of both areas totaling 3.6 cm.

"This would be considered a complex repair, and we would combine the length of the repaired wounds and code for that in addition to the two excisions," explains Richardson.

On the claim, you'd report the following for the lesion removals:

• 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 2.6 cm to 7.5 cm) for the complex repair (add 0.4 cm and 3.2 cm to decide on total repair area)
• 11444 (... excised diameter 3.1 to 4.0 cm) for the lip lesion excision
• 11440 (... excised diameter 0.5 cm or less) for the nose lesion excision
• The appropriate modifier (if necessary) appended to 11440 and 11444 to show that the lesion removals and repair were separate services.