General Surgery Coding Alert

Coding from the pathology report alone could lead you to downcoding or upcoding errors.

When you-re coding lesion excisions, you have to work your way through several steps before you actually determine the proper code to report. With several potential pitfalls along the way, choosing the right code can be a challenge. Take a look at these expert tips to be sure you-re not falling victim to excision coding myths.

When choosing a lesion excision code, you first need to look at the pathology report to determine if the lesion was benign or malignant. When reporting lesion excision, you-ll choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions.

Once you know the pathology of the lesion, you should narrow your code choice further based on which body area the surgeon operated on. For coding purposes, CPT breaks lesion removal codes into three body areas:

To continue on the excision coding path, you need to choose the correct lesion size. When you-re calculating lesion size to determine your code choice, don't just look at the lesion size. Be sure to report the total excised diameter on the claim.

The CPT manual says that you should take the greatest diameter of the lesion, plus the margins necessary to excise the lesion, says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio.

"Their examples all show equal margins, which would probably be the most common type of excision. They don't address unequal margins," Lamm explains. For uneven margins the correct method is to take the size of the lesion at its greatest width, plus two times the narrowest margin, he adds.

"As part of their training, some doctors have learned that, for benign lesions, they-re not supposed to add the margins in to get the pre-excision measurement, which, of course, clashes directly with CPT instructions," says Joanne Schade-Boyce, RDH, MS, CPC, ACS, PCS, owner of FairCode Associates in Towson, Maryland.

Example: The physician excises a benign lesion (see Figure 1 below) from a patient's left shoulder. The lesion measures 1.5 cm at its widest. To ensure removal of all malignancy, the physician allows a margin of at least 1.5 cm on all sides.

In this case, add the size of the lesion (1.5 cm) and double the width of the narrowest margin (1.5 cm x 2 = 3 cm) for a total of 4.5 cm (1.5 + 3 = 4.5). The appropriate code in this case is 11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter over 4.0 cm).

Bonus: "Adding the margins increases the size of the excision and usually the reimbursement to the physician and/or facility," says Schade-Boyce. "The purpose, however, should not be guided merely by reimbursement, but rather coding accuracy."

You should always choose a code based on the size in the physician's documentation, not the size documented in the pathology report.

"You should ask the physician to measure the lesion and the margins that they are going to take before they even remove it," says Christie Thomas, CPC, PCS, coder for Mercy Physicians Group in Fort Scott, Kan. "It is not really a good idea to code from the path report as the specimen will shrink in the formalin."

Once the specimen is put in the jar and sent to pathology, the specimen shrinks down, sometimes to half its original size. Therefore, if you-re coding from the size listed on the pathology report, you could be undercoding by almost half the size, which will cost you up to $20 per excision.

Caution: "Often you will read that the surgeon excised the lesion in an elliptical fashion," says Schade-Boyce. "Some doctors and surgical nurses have quoted to me that 90-95 percent of lesion excisions are done elliptically because the resulting scar is more aesthetically pleasing."

Because of the elliptical shape, the size documented in the pathology report might be the specimen size, not the lesion size, and therefore might be a lot bigger than the actual lesion and its margins. In this case, if you-re coding from the path report, you could be seriously overrcoding, Schade-Boyce warns. This could lead to overpayment and could also put you on the watch list with your payer and even the Office of Inspector General (OIG).

Example: The physician excises a benign lesion from just below the patient's right shoulder. The lesion measures 2 cm at its widest. To ensure removal of all malignancy, the physician allows a margin of at least 1.5 cm on all sides. In addition, the physician slightly lengthens the margins at two ends to allow the wound to heal with a less obvious scar (see figure 2 below).

To calculate the excised diameter, you should begin with the size of the lesion (2 cm) and add the width of the narrowest margin multiplied by 2 (1.5 x 2, or 3 cm total) for a total of 5 cm (2 + 3 = 5). In this case, you should also report 11406.

Note: The specimen size is much larger than the actual lesion size. If the specimen size is the only recording on the pathology report and you select your code based on the size in the pathology report, then you would be upcoding because the size of the total excision is much greater than the size of the lesion plus the margins.