ED Coding and Reimbursement Alert

Pathology procedures will shrink lesion and your ED's reimbursement

When patients with lesions report to your ED for treatment, you-ll need to answer several questions to submit a spot-on claim.

To properly report lesion removals, coders need to know the lesion type, the body area, and the exact measurement of the excised area. Getting just one of these wrong can result in a miscoded claim, and a denial.

Follow this expert advice to choosing the proper lesion excision code for each encounter.


Determine Lesion Type First

On your lesion excision claims, you should know whether the physician removed a benign or malignant lesion from the patient, says Sean Weiss, CPC, CMPE, founder of the Complete Medical Consulting (CMC) Group in Atlanta. When reporting lesion repair, choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions, he says.

Benign or malignant? There is no way for the coder to know whether the excised lesion was benign or malignant on her own, but she cannot choose the appropriate excision code without a benign or malignant diagnosis. ED physicians rarely treat malignant lesions, so some ED coders will report the lesion as benign without confirmation, according to Sharon Richardson, RN, compliance officer with Emergency Groups- Office in Arcadia, Calif.

However, if you want to know the lesion type before coding the excision, you should wait on the pathology report, Richardson says.

That way, you-ll know for sure whether your physician treated a benign or malignant lesion, and your diagnosis coding will be more exact.


For Coding, CPT Breaks Body into 3 Areas

Once you confirm whether the lesion is benign or malignant, you should narrow your code choice further based on which area of the body the physician operated on. For coding purposes, CPT breaks lesion removal codes into three body areas:

- trunk, arms, legs (11400-11406, 11600-11606)

- scalp, neck, hands, feet, genitalia (11420-11426, 11620-11626)

- face, ears, eyelids, nose, lips, mucous membrane (11440-11446, 11640-11646).

So if the ED physician removes a malignant lesion from a patient's left leg, youchoose the appropriate lesion excision code from the 11600-11606 code set.

Exception: If the ED physician is treating a patient for hidradenitis (705.83), you will not choose from the above codes, Richardson says. On hidradenitis repairs, you would choose the appropriate code from the 11450-11471 code set.

Include Margins on Lesion Measurements

Once you have discovered the lesion type and location, you-re ready to record the lesion's exact measurement for reporting purposes. When calculating lesion size, don't just measure the lesion: be sure to report the total excised diameter on the claim, Weiss says.

To determine the appropriate lesion excision size, measure the lesion's widest diameter point, then add double the width of the narrowest margin.

According to CPT, -Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter).-
 
Consider this example: The physician treats a lesion on a patient's left arm. The operative report indicates that the lesion was benign, its diameter was 1.4 cm at the widest point, and the physician also excised a skin margin of 0.2 cm on either side
 
You would add the lesion diameter (1.4) and the margin (0.2 + 0.2), and your total excision area would be 1.8 cm. On the claim, you should report 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter 1.1 to 2.0 cm) for this encounter.
 
Best bet: Since lesions will shrink when the pathologist analyzes them, the physician should measure and document the excision area before sending the lesion to pathology. 
 
Excisions From Same Area Offer 2 Coding Choices
 
There are instances in which the physician removes multiple lesions from the same body area. When this occurs, coding will depend on the number of incisions the physician makes.
 
Single excision: If the physician removes multiple lesions via the same incision site, you should tally the total size of the excision and report one CPT code, Richardson says. For instance, let's say the physician removes two benign lesions on a patient's neck via the same incision: each lesion measures 1.0 cm, and there is a 1.0-cm margin between them.
 
In this scenario, you would add each lesion size and the skin margin, giving you a total excision area of 4.0 cm. On the claim, you should report 11424 (... excised diameter 3.1 to 4.0 cm)

Multiple excisions: Basically, multiple lesions removed via multiple excisions equal multiple excision codes. For example, the physician removes a 1.0-cm benign scalp lesion with a 0.5-cm margin. During the same session, he also excises a 0.5-cm benign neck lesion with a 0.2-cm margin.
 
Since the physician performed two incisions on the patient (one on the scalp, one on the neck), you-d report a CPT code for each excision.

On the claim:
 
- report 11422 (... excised diameter 1.1 to 2.0 cm) for the excision of the scalp lesion.

- report 11421 (... excised diameter 0.6 to 1.0 cm) for the neck lesion excision.

- attach modifier 59 (Distinct procedural service) to show that the excisions were separate procedures, even though they occurred in the same body area.


If Body Areas Differ, Leave Modifiers off Claim

When the excisions occur in different body areas, things are less complicated for the coder. You-ll report two codes in these scenarios, and modifiers are unnecessary, says Pat Strubberg, CPC, of Patients First Health Care in Washington, Mo.

So let's say the emergency physician removes a 0.8-cm benign lesion from a patient's lip with a 0.2-cm margin, then excises a 1.0-cm benign lesion from a patient's neck with a 0.3-cm margin.

On the claim:

- report 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 lip lesion excision.

- report 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) for the neck lesion excision.