General Surgery Coding Alert

Append modifier 58 for OR re-excisions during global period

Coding all services involved in a lesion removal can quickly lead you into -gray- areas, such as determining if you should report a separate E/M service when performing minor excisions in the office.

Use these three case studies to understand how you should handle confusing lesion coding scenarios.

Case Study 1: Referral With Simple Excision

A family physician (FP) refers a patient to your general surgeon for excision of a -mole- on the patient's upper left arm. The surgeon suspects that the mole is a small basal cell carcinoma. She performs an excision to remove the lesion, which measures 0.9 cm with margins, in the office. She then closes the wound via simple repair and releases the patient.

How to code: In this case, you would probably report the excision alone (11601, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.6-1.0 cm).

-Because the referral was for specific removal, I understand there is no billable E/M service, especially if the surgeon can identify the lesion by simple exam,- says South Carolina general surgeon M. Trayser Dunaway, MD, FACS.
 
The bottom line: All procedures include a -minimal- E/M, so unless the surgeon can provide documentation for a significant, separately identifiable E/M service above and beyond that usually included in the excision, you are limited to reporting the excision only.

Learn more: Look to next month's General Surgery Coding Alert for more information on reporting a separate E/M with a same-day procedure or service.
 
Case Study 2: Referral With Unexpected Findings
 
In the next instance, the FP refers the patient to the surgeon for a skin lesion removal. This time, however, the surgeon views the lesion as potentially more serious and not diagnosable by simple exam. The surgeon performs a thorough exam and punch biopsy to determine the nature of the lesion. The biopsy returns positive for malignancy, and the surgeon schedules the patient for excision at a later date in the operating room (OR).

How to code: First, you should report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

In this case, if the surgeon documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...). -This was not a simple evaluation,- Dunaway says. -The surgeon had to spend considerable time with the patient.-

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to distinguish the E/M service as significantly above that included with the biopsy, says Lisa Lee, RN, CPC, remote instructor for the CRN Institute in Absecon, N.J., and an independent coder for The Coding Network in Beverly Hills, Calif

On the later date of the excision, you will report the excision (for instance, 11604, -excised diameter 3.1 to 4.0 cm), as well as any allowable wound repair (such as 12032, Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 to 7.5 cm).
 
Case Study 3: One Lesion, Multiple Excisions
 
The surgeon suspects squamous cell carcinoma and excises the lesion in the office. The pathology report returns later showing positive margins--meaning that the surgeon did not remove all the malignancy and must excise additional tissue. The surgeon schedules an additional excision for wider margins in the OR and takes a frozen section. This time the pathology report returns negative.
 
How to code: Report the initial excision (for example, 11601), as well as any allowable wound repair and E/M services that the surgeon provides in his office.

For the additional excision on a later day in the OR, report another excision code as appropriate to the size of the tissue removed (for example, 11604, -excised diameter 3.1 to 4.0 cm), as well as any allowable wound repair. Because the re-excision took place during the initial procedure's global period, you must append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the lesion excision code, Lee says.

The surgeon will want to excise all malignant tissue on the first try, but if he doesn-t, he-ll have to go back as many times as necessary to ensure he has provided adequate margins, Dunaway says.

Diagnosis tip: If the surgeon excises a malignant lesion and must re-excise the same lesion to ensure adequate margins, you should use the same diagnosis for the re-excision as you did for the initial excision, even if the pathology report for the re-excision returns negative for malignancy, according to AMA recommendations.