General Surgery Coding Alert
Put Some Skin in the Game With These Lesion Coding Scenarios
Don’t miss the musculoskeletal options. With so many code choices for surgical procedures to diagnose or treat skin and soft-tissue lesions, just getting to the correct CPT® chapter — not to mention the correct code — can be a challenge. Study the following five case details to identify key information in the medical record that will help you zero in on the right code. Case 1: Destruction The surgeon uses a cryoprobe to treat a patient for nine warts on the left knee, two warts on the plantar aspect of the right hallux, and six warts on the right hand. Report the service as 17111 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions). Notice that the code definition embraces any method of destruction, including cryosurgery, the method used in this case. “Integumentary lesion destruction is all about the numbers. It’s important to know how many were removed, what type of lesion, and how the lesions were destroyed,” says Sydni Young, CPC-A, medical coder II for Healthcare Resource Solutions in Evansville, Indiana. The case count for this encounter is 16 warts, so you should choose 17111 instead of 17110 (… up to 14 lesions). Consider diagnosis: Warts are benign lesions, but you should turn to the following destruction codes for other conditions: Destruction procedures do not typically involve closure. Case 2: Shave The patient complained of continual irritation due to chafing at the site of a 1.4 cm seborrheic keratosis on her waistline. The surgeon used a flexible blade slicing horizontally across the lesion, removing tissue to create a slight indentation of the lesion relative to the surrounding skin surface. Code this procedure as 11302 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm). Depth: Shave procedures involve sharp removal of epidermal and dermal skin layers without a full-thickness excision, often leaving part of the lesion intact. Purpose: Clinicians often use shave procedures to treat “nuisance” conditions, not for diagnosis or treatment of lesions that pose a risk of neoplasm. Closure: Shaves don’t involve closure methods, such as sutures, but typically involve healing by secondary intention. Site and size: Choose the appropriate shave code from the range 11300-11313 (Shaving of epidermal or dermal lesion, single lesion …) based on anatomic site and diameter of the lesion without considering margins. Case 3: Biopsy The patient presents with a dark, irregular 0.8 cm lesion on the left forearm. Using a scalpel, the surgeon cuts down through the epidermis and dermis, removing a small irregular edge of the lesion and submits it for pathology. The surgeon closes the site of the removed wedge with a single suture. Report the procedure as 11106 (Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion). Purpose: Clinicians use a biopsy to remove tissue for pathologic diagnosis. The aim is not to remove the entire lesion or to treat the condition. Closure: If the surgeon closes the biopsy site with a single layer method such as sutures, the biopsy code includes that work. Method: CPT® provides three skin biopsy code families based on the surgical method: Per lesion: Each parent code describes the biopsy for the first lesion during the surgical session, and each add-on code describes each separate/additional lesion during the session. Look for specific sites: CPT® provides a few specific skin biopsy codes for certain sites, such as lip (40490, Biopsy of lip), eyelid (67810, Incisional biopsy of eyelid skin including lid margin) and ear (69100, Biopsy external ear). When a specific code is available, you should use it instead of a general skin biopsy code from the range 11102-+11107. See a complete list of these “alternate” biopsy codes in the CPT® instructions for the biopsy section. Case 4: Excision (benign or malignant) Following a melanoma diagnosis from the biopsy of a 0.8 cm lesion on the left forearm, the surgeon creates an elliptical incision down to the fascia with the smallest margins of 0.2 cm and closes the surgical site with seven sutures. The correct code for the procedure is 11602 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm). Depth: Skin excisions involve full-thickness tissue removal through the dermis down to the fascia, but generally not into the subcutaneous tissue. Purpose: Clinicians perform excisions to remove an entire lesion and a safe tissue margin with the intention of treating a condition such as cancer or pre-cancerous changes. Closure: Skin excision includes simple closure, but “intermediate and complex closures are separately reportable with 12031-12057 (Repair, intermediate …) for intermediate closures or 13100-+13153 (Repair, complex …) for complex closures,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Diagnosis: CPT® divides skin excision codes between benign (11400-11446, Excision, benign lesion including margins, except skin tag (unless listed elsewhere) …) and malignant (11600-11646, Excision, malignant lesion including margins …) lesions. Site and size: Within the benign and malignant lesion excision code ranges, CPT® creates code families based on anatomic site (such as trunk arms or legs; or scalp, neck, hands, feet, genitalia). Once you get to the family with the correct anatomic site, you can zero in on the correct code based on the lesion size range (such as 1.1 to 2.0 cm). Remember that the size for excision cases is the lesion diameter plus two times the smallest surgical margin. That’s why the above excision case example had a lesion size of 1.2 cm (0.8 cm plus (2 x 0.2 cm) = 1.2 cm). Case 5: Musculoskeletal The preceding cases were all skin deep. But what if the procedure goes deeper. For instance, in another case, the surgeon removes a 2 cm subcutaneous lipoma from the patient’s left shoulder. You should code the case as 23075 (Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm). Or deeper: If the surgeon had documented that this lesion extended into the subfascial or intramuscular tissue, you would have listed 23076 (… 3 cm or greater). Diagnosis: Depth isn’t the only factor leading you to the musculoskeletal codes. For instance, if the surgeon is treating a skin cancer that has progressed into the subcutaneous tissue, you should still use the skin excision codes. Reserve the musculoskeletal codes for conditions that arise in those tissues, such as lipoma or soft-tissue sarcoma.
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