General Surgery Coding Alert

Tip: Rules for laceration repair don't apply to excision procedures

When your physician excises multiple lesions, don't make the common mistake of adding together the area of the several lesions and reporting a single excision code.

Instead, you should bill for each lesion separately, using modifier 59 (Distinct procedural service) to clarify that the excisions took place at separate locations. The only exception occurs in the rare case that the surgeon excises two separate lesions using a single excision.

Different Procedures Call for Different Guidelines

Some coders, especially those who are less familiar with integumentary coding, become confused because the rules for laceration repairs (12001-13160) state that you should add the lengths of tissue repaired and report a single code, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Evanston, Ill.

Lesion excisions are different, however, in that you should select a code based on the lesion's size at its widest point plus double the width of the narrowest margin, Gilhooly says.

Important: You should treat each lesion separately, rather than add the excisions together to select a single -cumulative- code.

Single-lesion example: The surgeon excises a malignant lesion (as determined by pathology) from just below the patient's right shoulder. The lesion measures 2 cm at its widest. To ensure removal of all malignancy, the surgeon allows a margin of at least 1.5 cm on all sides.

To calculate the excised diameter, you should begin with the lesion's size (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. In this case, therefore, you should report 11606 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter over 4.0 cm).

Multiple-lesion example: The surgeon removes three lesions, all from the left arm, with sizes 1 cm (benign), 1.5 cm (benign) and 2.5 cm (malignant), including margins.

In this case, you should report 11603 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm) with 173.6 (Other malignant neoplasm of skin; skin of upper limb, including shoulder), 11402-59 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) with 216.6 (Benign neoplasm of skin; skin of upper limb, including shoulder), and 11401-59 (... excised diameter 0.6 to 1.0 cm) with 216.6.

Watch for Alternative Scenarios

When the surgeon uses a single excision to remove two separate but closely positioned lesions, you would include the space between the lesions as a clean margin. This isn't really the same as -adding- the two lesions together, Gilhooly adds. It's just using the rule of -size of the lesion plus the size of the margin,- as described above.

Example: The patient presents with two malignant lesions on the left forearm. The lesions are 1 cm in diameter at the widest point and are spaced 1 cm apart. The surgeon removes both lesions using a single excision, allowing a margin of 1 cm on all sides (see illustration).

In this case, you would report a single code to describe the removal because it involves a single excision. Because the total area equals 4 cm (1 cm x 2 for each of the lesions and 1 cm x 2 for -double the width of the narrowest margin-), you would report 11604 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to 4.0 cm).

You would almost never see this scenario, however, says Christine Liles, CPC, insurance supervisor with Knoxville Dermatology Group in Knoxville, Tenn. She encourages her doctors to remove each lesion separately, whenever possible.

Watch out: Some private payers have different policies, says Detroit physician Craig Gastwirth. Payers may require you to combine the sizes of the lesions and code for that combined area, he says. Blue Cross Blue Shield of Michigan has this policy and has published it in its provider bulletin, he adds.

Take-away point: Check with your non-Medicare payers to determine if they treat lesion excision differently than CPT and CMS recommend.