General Surgery Coding Alert

Closure documentation could earn $162 pay.

When your general surgeon performs a tongue lesion excision or biopsy to aid in the diagnosis of lingual cancers such as a squamous cell carcinoma of the oral tongue, you’ll need to be armed with some anatomical facts and code know-how to get the pay your surgeon deserves.

Not only that, choosing the right ICD-10-CM code depends on your surgeon accurately documenting the location of the excised lesion, as well as the final diagnostic statement of the pathologist in the case. Read on for expert advice to help you choose the correct procedure and diagnosis codes for your tongue excision cases.

Choose Procedure Code Based on Location

When you report a tongue-lesion biopsy procedure, you will need to choose from one of two CPT^® codes based on where the lesion is located on the tongue.

“The site of the cancer should coordinate with the gross pathology specimen description,” says Barry Shipman, DMD, clinical professor, University of Florida School of Dentistry, Hialeah Dental Center. The portion of the tongue on which the surgeon performs the procedure distinguishes the biopsy codes from one another, as follows:

• 41100 — Biopsy of tongue; anterior two-thirds
• 41105 — ... posterior one-third

Lesion excision is different: In addition the two biopsy codes, CPT^® provides three different codes for tongue lesion excision. In these procedures, the surgeon attempts to remove an entire small lesion with clear margins, as opposed to simply sampling a part of a lesion in a biopsy procedure.

To select the proper lesion excision code, you’ll need to know the location on the tongue, as well as whether the surgeon used sutures or other wound closure methods after removing the tumor. For these services, choose one of the following codes:

• 41110 — Excision of lesion of tongue without closure
• 41112 — Excision of lesion of tongue with closure; anterior two-thirds
• 41113 — ... posterior one-third

Coding tip: If your surgeon excises a tongue lesion without closure, you should use 41110 whether the lesion is in the anterior two-thirds or the posterior one-third.

But when your surgeon excises a lesion and performs a closure of the surgical site, you’ll have to consider the location to select the proper code (41112 or 41113). “Due to the fact that the tongue is a muscle, many anterior, or posterior lesions of the tongue can be closed primarily,” Shipman adds.

Example: Your surgeon examines a 25-year-old male patient with complaints of a painful growth in the left margin of the tongue near the wisdom tooth. The patient says that the mass has been slowly increasing in size and has attained the current size of about 1cm in diameter and has become painful over the past month or so. The surgeon excises the lesion and sends it to the lab for pathological examination. The surgeon closes the excision site with sutures because the lesion was located deep in the submucosal area.

Do this: Because the excised lesion was in the posterior one third of the tongue and your surgeon performed closure of the surgical site, you should report 41113. If you failed to note the closure and instead reported 41110, your error would cost the surgeon $161.83 of legitimate pay (based national non-facility amount $221.63 for 41110 and $383.46 for 41113, conversion factor 35.8043). 

Focus on Tongue Anatomy for Malignant Lesion Diagnosis

When a tongue pathology report returns with a statement of malignancy, you’ll need some excellent anatomical knowledge to select the proper diagnosis code.

Unfortunately, your surgeon might not always use the specific terms that are in ICD-10 code descriptors. We’ve got some tips so you can equate your surgeon’s documentation with the most accurate diagnosis code.

• C01 — Malignant neoplasm of base of the tongue
  The tongue is divided into the anterior two-thirds and the posterior one-third by the circumvallate papillae. Behind (or posterior to) the circumvallate papillae is the base of the tongue. The circumvallate papillae are important guidelines when determining which part of the tongue your surgeon treated. These are the big taste buds on the back of the tongue, which are in the shape of a V. Therefore, if your surgeon documents any lesions on the posterior tongue, the root of the tongue, or behind the circumvallate papillae, he is most likely referring to the base of the tongue.
• C02.0 — … of dorsal surface of tongue
  This refers to the top of the tongue anterior to (or in front of) the circumvallate papillae. If your surgeon documents a lesion to the midline of the tongue, the dorsal anterior two-thirds, or the fungiform papillae, you should report C02.0.
• C02.1 — … of border of tongue
  You will find most tongue cancers in this area, which includes the sides of the tongue and the tip. Your surgeon may refer to the tip as the apex.
• C02.2 — … of ventral surface of tongue
  Your surgeon may refer to the ventral surface when he treats the underside of the tongue. He might also document attention to the frenulum, the plica fimbriata, or the sublingual fold, because these sites are all on the ventral surface.
• C02.3 … of anterior two-thirds of tongue, part unspecified
  If your surgeon treats a lesion in the anterior two-thirds of the tongue (anterior to the circumvallate papillae) but does not specify where, you should report this code.
  Tip: The anterior two-thirds does not refer to the top of the tongue only. The ventral tongue is always considered part of the anterior two-thirds. Therefore, if your surgeon simply documents that he focused on the anterior two-thirds but you don’t know whether it was the ventral or dorsal surface, you can still report C02.3.
• C02.8 … of overlapping sites of tongue
  

This includes cancer that spreads across several sections of the tongue, or cancer between the oral cavity and the oropharynx, which the surgeon may refer to as the “junctional zone” of the tongue.

• C02.4 — … of lingual tonsil
  The lingual tonsil lies in the posterior one-third of the tongue. This area is made up of bumpy follicles near the back of the tongue

• C02.9 — … unspecified
  Use this code if the surgeon doesn’t document the lesion location on the tongue.

Documentation tip: You can best identify where the lesion is located on the tongue “by having your surgeon draw a simplified diagram of the tongue and its anatomy,” Shipman says.