General Surgery Coding Alert

Incorrectly coding lipomas as lesions can lead to drastically reduced reimbursements.

If coders arent clear about the definition of lipoma, dont read the operative report thoroughly or dont get clear information about the procedure from their surgeons, they mistakenly may go to the CPT integumentary section and bill for a lesion instead, says Janine Valentine, CPC, senior coder with Facey Medical Foundation, a multispecialty group of 109 providers, including four general surgeons, in Mission Hills, CA.

Even general surgeons can mark down excision of lipoma-flank as a lesion, and unless the physician dictates an accurate note or the coder reads the operative report, its hard to differentiate between the two procedures, Valentine says.

Valentine gives the following example: A patient sees the general surgeon about a mass in his flank, and the surgeon diagnoses 239.2 (neoplasm of unspecified nature; bone, soft tissue, and skin). In an outpatient surgery setting, the physician removes the mass but mistakenly marks down the procedure as removal of lesion. Without reading the operative report, the coder may bill out the procedure as 11404 (excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs), when, in fact, the actual procedure performed was 21930 (excision, tumor, soft tissue of back or flank) and the post-operative diagnosis was 214.1 (lipoma, other skin and subcutaneous tissue).

Mislabeling the lipoma removal as an excision of a lesion is a costly error. If the procedure described above was inadvertently billed as a 11404 (lesion excision, 3.1-4.0 cm in diameter), it is assigned only 3.83 relative value units (RVUs), according to Medicares 1999 National Physician Fee Schedule Relative Value Guide, while the correct procedure, 21930, is worth 8.3 RVUs.

Note: RVUs vary from state to state. The figures quoted above were taken from the Health Care Financing Administration Web site (http://www.hcfa/gov).

Four Steps to Follow

To find the right CPT code you need to know the definition of lipoma (a non-cancerous fatty tumor) and the growths location in the body. Since lipomas are usually found in subcutaneous tissue not in the skin the musculoskeletal section of CPT is the place to look says Kathleen Mueller RN CPC CCS-P a registered nurse and reimbursement and coding specialist in the office of Allan L. Liefer MD a general surgeon in Chester IL.

Many general surgery coders look at lesion size when coding for a fatty tumor she says. They go to the integumentary section of the CPT book because they think the musculoskeletal section applies only to orthopedics not to them. And they dont venture beyond where they believe they are supposed to look.

Mueller notes that unlike the removal of lesions size is not a factor in the descriptions of excisions in the musculoskeletal section. Rather the determining factor is the removed tumors depth in the body.

The musculoskeletal section begins with the 20000-series codes. It is subcategorized by parts of the body beginning with the head and then the neck back and flank spine shoulder and so on. Every section has an excision category Mueller says which is further subcategorized into three different kinds of tumor removalssubcutaneous deep and radicaland thats where coders should be looking rather than excisions in the skin.

The musculoskeletal section contains these categories in all anatomic areas except for the face which has only the category of radical resection and the abdomen which has only code 22900 (excision abdominal wall tumor subfascial [e.g. desmoid]).

Note: Although CPT gives the example of desmoid for 22900 other diagnoses including lipoma and benign neoplasm connective tissue also may be used when charging for it.

To locate the correct code when billing for excision of lipoma coders should follow these four steps:

- Go to the musculoskeletal section in CPT.
- Find the part of the body where the excision was
performed (i.e. shoulder).
- Locate the excision codes for that particular body
area.
- Read the operative report to determine whether the
excision was subcutaneous deep or radical.

Mueller cites the following scenario which she says most general surgeons commonly encounter:

Preoperative diagnosis: Mass right shoulder
left forearm and right thigh
Postoperative diagnosis: Lipomas right
shoulder left forearm and right thigh
Procedure: Excision of deep tumors right
shoulder left forearm and right thigh
Anesthesia: Local with IV sedation
Findings: This patient has had three masses in the areas noted above that have increased in size and are causing some discomfort. The right shoulder mass was 3 cm left forearm mass was 2.5 cm and the thigh mass was 4.3 cm. All three areas extended into the muscle and caused increased dissection.

Excision of a tumor in the right shoulder falls under three subcategories depending on how deep the tumor extends into the body Mueller says. The codes in this scenario are 23075 (excision soft tissue tumor shoulder area; subcutaneous); 23076 (excision soft tissue tumor shoulder area; deep subfascial or intramuscular); and 23077 (radical resection of tumor [e.g. malignant neoplasm] soft tissue of shoulder area) depending on whether it was subcutaneous deep or radical.

To make that determination Mueller says you must read the operative report thoroughly. Even though the op note may say deep at the top you must read on into the procedure itself to make sure the excision extended below the fascia or intramuscular layers. If it did not you should code only the subcutaneous excision. Lipomas often have tentacles that extend below the fascia and into the muscular layer which makes the procedure to remove them more difficult. General surgeons need to be told that the extent of the excision needs to be described not only the size she adds.

In the scenario above the correct codes (23075 25076 [excision tumor shoulder area; deep] and 27328 [excision tumor thigh; deep]) have a total of 31.50 RVUs. Had the coder incorrectly ventured into the integumentary section of CPT and coded based on lesion size the lesion excision codes used (11402 1.1-2.0 cm; 11404 3.1-4.0 cm; 11406 over 4.0 cm) total only 11.54 RVUs which translates to a nearly two-thirds loss of reimbursement.

Note: The 23075 25076 and 27328 are not bundled together and therefore may be billed separately. Depending on your carrier modifier -51 (multiple procedures) does not necessarily need to be added to the second and third code.

General surgeons should note that in the above scenario the preoperative diagnosis says mass while the postoperative diagnosis is lipoma (214.1). Because lipomas are not symptoms but rather a pathology diagnosis coders should avoid using the specific diagnosis code for lipoma until the mass is removed and the pathology report returns. Instead they should use signs and symptoms.

Signs symptoms and abnormals are excellent diagnoses and usually warrant further investigation therefore backing up the need for a visit to determine a diagnostic or treatment plan Mueller says.

Coding for Lipomas on the Same Site

Sometimes more than one lipoma may be located in the same area of the body and at the same depth. For example a patient may have three lipomas all of which are located on the left thigh and are deep. To correctly code for such occurrences the same diagnosis code (214.1) would be usedonce the operative note and pathology reports have been readand code 23076 (excision biopsy soft tissue tumor shoulder area; deep subfascial or intramuscular) would be charged three times with modifier -59 (distinct procedural service) attached to the second and third code to indicate a separate site on the thigh Mueller says.

Sometimes a carrier may request an operative report to verify the different sites she adds emphasizing that general surgeons should not write off the second and third procedures automatically because submitting the op note and underlining each separate procedure on each area of the thigh usually will result in all three procedures being paid.

One final reminder: You should have the patient sign a waiver of medical necessity prior to scheduling the procedure because some carriersboth Medicare and non-Medicareconsider excision of lipomas cosmetic and not medically necessary. It is also important to ensure that the physician documents the medical necessity of the procedure in the initial visit. Remember just because you received authorization does not mean that it is a covered benefit."