Case Study:
Documentation is Key to Getting Paid for Excision of Lesions
Published on Tue Aug 01, 2000
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 [...]
