General Surgery Coding Alert

When surgeons remove multiple benign lesions from a patient, each excision should be billed separately, depending on the size of the lesion and its location on the body. If more than one similarly sized lesion is removed from the same body category, each excision should be billed separately with modifier -59 (distinct procedural service) attached, coding experts say.

In the following operative report, the surgeon removed 16 nevi from a 40-year-old (non-Medicare) patient with dysplastic nevus syndrome. Of these, 14 were in the same category based on body area, and 10 were in the same size category. (A dysplastic nevus is defined as an acquired atypical nevus with an irregular border, indistinct margin, and mixed coloration, often occurring in large numbers, that is characterized by intraepidermal melanocytic dysplasia and often is a precursor of malignant melanoma.)

To correctly bill for these procedures, the size of the lesion must be documented before the specimen is sent to pathology. In addition, because more than five lesions were excised at the same time, the carrier is likely to request supporting documentation, including the pathology report, before the claim will be paid.

The pathology report could also be included because the surgeon did not note the size of the lesions before they were removed.

Coding the Operative Session

The operative session is coded as follows, in descending order of relative value units (RVUs) per procedure:

11441 excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm, 2.51 RVUs
11402 excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2 cm, 2.44 RVUs
11401 excision, benign lesion, except skin tag (unless
listed elsewhere), trunk, arms or legs; 0.6 to 1 cm, 2.04 RVUs
11401-59
11401-59
11401-59
11401-59
11401-59
11401-59
11401-59
11401-59
11401-59
11420 excision, benign lesion, except skin tag (unless
listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 or less, 1.66 RVUs
11400 excision, benign lesion, except skin tag (unless
listed elsewhere) trunk, arms or legs; 0.5 cm or less, 1.48 RVUs
11400-59
11400-59

Due to the extensive number of procedures claimed, three HCFA 1500 claims forms would be required, as each form allows for a maximum of six procedures.

Note: The RVU values will vary according to geographic location.

The diagnosis code should reflect the findings in the pathology report, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C. In this case, the pathologist diagnosed the first specimen as an intradermal nevus, and the second through sixth specimens as compound nevi. This means the nevi are benign. Therefore, the diagnosis codes would describe benign neoplasms as follows:

216.3 skin of other and unspecified parts of face; eyebrow
216.4 scalp and skin of neck
216.5 skin of trunk, except scrotum, including back and chest wall

Diagnosis code V13.3 (personal history of disease of skin and subcutaneous tissue) should be listed as the second diagnosis code for all the procedures, because it indicates the medical necessity of the excisions, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. In addition, dysplastic nevi syndrome should be indicated in box 19 (the comments box) on the claims form to help decrease the possibility of the claim being denied as cosmetic.

Because most of the lesions were in the same size and area category, modifier -59 should be attached to all identical codes after the first one listed, Mueller says. In this instance, 10 excisions were on the trunk or back and were 0.5 to 1 cm in diameter, so the last nine claims should be appended with modifier -59 to indicate that the excisions were performed on separate sites.

Even with modifier -59 attached, the number of excisions performed makes it likely that many of the 16 claims will be denied when first submitted to the carrier. On appeal, the surgeon will need to provide detailed supporting documentation to prove that the 16 excisions actually were performed.

Note: If the claim is sent in manually, some carriers may pay for it on first submission, as long as the HCFA claims form is accompanied by the operative note and pathology report.

The surgeon also may need to indicate to the carrier the medical necessity for removing the nevi, Callaway-Stradley says. Moles often are removed for cosmetic purposes, and most carrier policies do not cover cosmetic procedures. The fact that the surgeon documented that the patient has both a family history of melanoma and a personal history of dysplastic nevi provides the medical necessity for the procedure.

Tip: Even though it is not required with non-Medicare patients, surgeons still should get their patients to sign a waiver stipulating that if the procedure is denied for cosmetic purposes, the patient will take responsibility for payment.

Use Pathology Report to Support Documentation

Because the surgeon did not note the size of the lesions prior to their excision, the correct codes for the procedures had to be determined by checking the pathology report, which, in addition to listing the total volume of the specimen that was taken, also lists the diameter of 14 of the 16 lesions that were removed.

Further, because the surgeon did not note the size of the remaining two lesions in the operative report, and because the pathology report does not describe their diameter either, only the code for the smallest lesion size in the category (i.e., 11400, for up to 0.5 cm) can be billed for those two excisions.

In this instance, the pathology report failed to describe the diameters of only two lesions. Mueller says pathology reports vary considerably, and some may not describe diameters at all.

In addition, because specimen size shrinks in the pathology lab, surgeons would likely be reimbursed more and provide more accurate information if they measured the size of the lesion before it was removed and noted it in their documentation.

If the surgeon forgot to include this information in the original operative note, an addendum may be included, if the information is available, in a progress report or consult report, Mueller says.

Note: Incorrectly sizing lesions at a higher level is a target for fraud investigators.

Operative Report Preoperative Diagnosis: Multiple nevi and dysplastic nevus syndrome Postoperative Diagnosis: Same Procedure Performed: Excision of 16 cutaneous lesions from thorax, base of neck, and head Anesthesia: Local with monitored anesthesia care Indications: The patient is a 40-year-old man with family history of melanoma. The patient had numerous unusual-looking nevi excised in 1966 and two of those demonstrated dysplastic characteristics. The patient returns at this time for multiple excision of irregular or unusual-looking nevi. Surgical Technique: The patient was taken to the hospital, where IV sedation was administered, and the patient prepped and draped in the usual sterile fashion. The back was first approached. There were a total of seven lesions excised from the back, and all were separately catalogued and submitted for pathology. Each was addressed in a similar fashion using local anesthetic of 1% Xylocaine with epinephrine and 0.25% Marcaine. Elliptical incisions were made approximating the lines of skin tension. Localized undermining was performed, and the wounds were closed after excision of full-thickness skin samples using interrupted subcuticular 4-0 Vicryl suture and steri strips. The anterior thorax was also done in a similar fashion, and in this area seven lesions were removed. There was one nevus on the left eyebrow that was excised with a transverse incision, and this was closed using interrupted 5-0 nylon sutures. There was also a large lesion protruding from the scalp, which was only lightly pigmented. This was extended fairly deep into the dermis and is most likely some type of fibroma. This was excised and the local scalp undermined. The wound in this area was closed using skin staples as the patients hair had been left and would interfere with suturing technique. Sterile dressings were applied to all of these wounds. The patient left the operating room in good condition. No intraoperative complications were encountered.