General Surgery Coding Alert

NCCI bundles remain in effect

If you had hoped you could report lesion excisions (11400-11646) separately with adjacent tissue transfers (14000-14350), be ready for disappointment. Unless the two procedures occur at distinct anatomical areas or during different sessions, you won't be able to receive separate payment for the lesion excision.

Background: The June 2006 General Surgery Coding Alert (page 44) reported: -NCCI 12.1 deletes one set of formerly troublesome edits. Starting in April, lesion excision codes 11600-11646 will no longer be components of tissue transfer or rearrangement codes 14000-14300.-

The update: The latest version (12.2) of the National Correct Coding Initiative again lists lesion excisions 11400-11646 as bundled to (included in) all tissue transfer codes in the 14000-14350 range.

And introductory text in NCCI's Chapter 3 (Surgery: Integumentary System) specifies, -Excision CPT codes (11400-11646) - are not to be separately reported when CPT codes 14000-14350 are reported.- These instructions mimic similar (although less clearly stated) guidelines set forth in the CPT manual.

Separate Surgeons Won't Mean Separate Payment

Continued bundling of 11400-11646 to 14000-14350 is bad news for general surgeons and plastic surgeons who work together, with the general surgeon performing the lesion excision and the plastic surgeon providing the adjacent tissue transfer.

Here's the problem: The physician fee schedule database indicates that you may not report co-surgeons using modifier 62 (Two surgeons)--or assistant surgeons using modifiers 80, 82 or AS--for adjacent tissue transfers 14000-14350, says Terri Brame, CPC, CPC-H, operations manager for the Division of Clinical Revenue at the University of Washington Department of Surgery.

Therefore, if a general surgeon removes a lesion and a plastic surgeon performs the adjacent tissue transfer later in the same session, you cannot list the surgeons as co-surgeons. And because the lesion excision is bundled to the tissue transfer, the general surgeon will have difficulty gaining payment for his portion of the service.

Possible solutions: In such a case, you have two possible solutions to be sure both surgeons receive payment:

Option 1. Each surgeon reports his portion of the service using modifier 52 (Reduced services). And depending on which surgeon will be assume post-op care, the other should report modifier 54 (Surgical care only).

Example: The general surgeon excises a lesion--for example, 11406, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter over 4.0 cm). The plastic surgeon then performs adjacent tissue transfer (for example, 14021, Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm). The plastic surgeon will assume post-op care of the patient.

In this case, you would report 11406-52 for the general surgeon. Your documentation should explain that the surgeon did not provide closure/wound repair for the excision. And because the plastic surgeon will provide post-op care, the general surgeon should also append modifier 54.

The plastic surgeon would report 14021-52, with documentation explaining that he did not perform the lesion excision.

-As you can see, this is a tricky situation, so I would be sure to ask the carrier for guidance before billing in this fashion,- Brame says.

Option 2. As an alternative, one physician may report the adjacent tissue transfer (without modifiers) and, through a separate billing agreement, reimburse the second surgeon for his portion of the service. But such an arrangement can be a hassle to coordinate.

Different Locations May Call for Separate Billing

The NCCI includes a modifier indicator of -1- for the edits bundling 11400-11646 to 14000-14350. This means that you may use modifier 59 (Distinct procedural service) to override the edits when the lesion excision and adjacent tissue transfer occur at different locations, or during separate, distinct operative sessions, says American Academy of Professional Coders National Advisory Board member Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHBME.

Example: The surgeon performs a single excision on the right forearm, along with lesion excision followed by adjacent tissue transfer at another location near the elbow.

In this case, you should report the lesion excision followed by adjacent tissue transfer using the appropriate tissue transfer code only (for example, 14021).

You may report the lesion excision only in a separate location using the appropriate lesion excision code (for example, 11601, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.6 to 1.0 cm) with modifier 59 appended.