General Surgery Coding Alert

Your general surgery practice is facing 72 new/revised codes for soft tumor excisions and resections in 2010, so you'd better get ready now. Let our experts explain how location, size, depth, and malignancy interact to help you select the right code from CPT's new soft-tissue tumor matrix.

Don't forget documentation: Unless your general surgeon documents the new criteria, you'll be stuck reporting lesser codes -- and reaping lesser pay. "The key is to have a conscientious surgeon who will be sure to dictate these findings in the operative report so the coder is successful in utilizing them," says Kristine Newton, CPC, a billing coordinator in Sarasota, Fla.

Look at these back and flank codes as an example of the 72 new and revised codes for soft tissue tumor removal:

• 21930 -- Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm

• 21931 -- ... 3 cm or greater

• 21932 -- Excision, tumor, soft tissue of back or flank, subfascial (e.g.,intramuscular); less than 5 cm

• 21933 -- ... 5 cm or greater

• 21935 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or flank; less than 5 cm

• 21936 -- ... 5 cm or greater.

Now that you're familiar with the format, follow these four tips to ensure that you select the proper code from the 72 soft tumor code choices.

You'll find the new soft-tissue tumor codes scattered throughout CPT's musculoskeletal surgery section (20000-29999). Like the rest of the procedures in this chapter, the new codes are organized by body site -- head, neck, back, abdomen,shoulder, etc.

The AMA updated soft-tissue tumor coding "to include other parts of the body that hadn't been included," said Albert E. Bothe Jr. MD, FACS, Geisinger Health System executive vice president and AMA CPT Editorial Panel member, at the CPT and RBRVS 2010 Annual Symposium in Chicago.

CPT 2010 provides codes for soft tissue tumor excision/resection for 12 separate anatomic parts of the body. Within each anatomic site, CPT lists codes from small lesions to radical resections. "We hope that with the symmetry infused into those areas, you won't have to guess where something would belong," Bothe said.

For each of the 12 body sites, CPT 2010 distinguishes the soft-tissue tumor excision codes based on whether theexcision is subcutaneous or subfascial.

Know your anatomy: The tumors described by these new codes originate beneath the skin (epidermis and dermis). You'll choose the appropriate code based on whether the tumor sits below the dermis in the subcutaneous layer or extends even deeper into and below the deep fascia. For instance, a lipoma is usually subcutaneous, but above the level of deep fascia,according to Bothe.

Document, document: Your physicians must document the depth of excision relative to the subcutaneous layer and the fascia so that you can choose the appropriate code. "Fascia can be a very important word," says Pam Biffle, CPC, CPC-I, CCS-P, CHCC,CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.

In addition to soft-tissue tumor excision codes, CPT 2010 also adds codes for radical resection of soft-tissue tumors for each of the 12 anatomic sites.

Beware: "The term 'radical resection' makes me nervous," Biffle says. First of all, "your physician has to specify that he went beyond the fascia" to use these codes.

But depth isn't the only criteria you'll have to use to distinguish deep excision and radical resection. Even if the tumor is through the fascia, you still may not have a radical resection. "Think of the radical resection in relation to malignant tumors," says Bothe.

The resection codes don't require cancer -- the definition states "e.g." (for example) in reference to malignant tumor. But your surgeon should document a tissue removal level and physician work that is equal to a malignant tumor removal before you use the resection codes. Typically, you would expect to use the radical resection codes when the physician removes a malignant soft tissue mass.

The final factor you'll use to zero in on the right code is tumor size. Within each excision/resection designation for each of the 12 body sites, you'll see soft-tissue tumor codes differentiated by whether the tumor is less than or greater/equal to a specific measurement.

Introducing lesion size allows the codes to "distinguish the [difference in] work between small and large lesions," Bothe says. That means payment will more closely reflect the work involved.

Know this nuance: The cut-off size is not the same for all body sites. For instance, 5 cm is the dividing size for subfascial anterior thorax tumors, but 2 cm is the dividing size for subfascial face tumors "because 2 cm is more significant on the face," according to Bothe.

Capture $$ with these documentation tips: The defining measurement is the size of the excision/ resection, not the size of the lesion. For instance, the surgeon might have to excise 7 cm to remove a 4.5 cm tumor. "If you document only the size of the lesion and not the resection size, you could end up with a lower code," Bothe cautions.

Measure before pathology: The surgeon should measure and document the resection size during surgery. Excised tissue shrinks dramatically during processing, so you'll under-size the excision if you base the measurement on the pathology report, according to Bothe.

Resource: Look for a "clip-n-save" chart in next month's issue of General Surgery Coding Alert to get the full picture of the soft-tissue tumor code matrix.