ED Coding and Reimbursement Alert

Question: A patient presents to the ED with a lesion on his forehead and one on his neck; he says the lesions "itch really bad." The patient is bleeding due to his scratching of the wounds. The physician performs an expanded problem focused history and physical exam. The patient has no access to a dermatologist, so the physician decides to excise the lesions herself. The physician performs a 1.6 cm lesion excision on the patient's forehead wound and a 1.8 cm lesion excision on the patient's neck wound. (The tissues are both benign.) The physician then writes prescriptions for antibiotics and Tylenol No.3 and discharges the patient. Do I need a modifier for the lesion repair codes?

Utah Subscriber

Answer:Maybe. Since the repairs occurred in two separate anatomical areas, most insurers will accept the repair codes without any modifiers. For this encounter, you'll typically report the following:

• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter1.1 to 2.0 cm) for the forehead repair for the forehead lesion
• 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 repair
• The appropriate-level E/M code (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ...) based on encounter notes
• 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 the E/M code to show that the E/M service and excisions were separate services.

Caveat: If you are unsure, and cannot find an answer in your payer contract, give the insurer a call before filing. Some insurers might want to see modifier 51 (Multiple procedures) or 59 (Distinct procedural service) appended to 11422