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General Surgery Coding Alert

Pathology Report Critical to Lesion Excision Coding

Published on Mon May 01, 2000

Nugget: If a surgeon excises more tissue to remove margins and the lesion turns out to be benign, wound closure may be billed in addition to the lesion excision.

To accurately bill lesion excisions, general surgery coders need to (as always) carefully talk to their surgeons, carefully read the operative report, and wait for the pathology report before submitting claims, coding experts say. In particular, waiting for the pathology report is crucial, because only then does the surgeon know for certain whether the lesion is benign or malignant.
 
The excision of a malignant lesion is reimbursed at a higher rate than that of a benign lesion because (1) the general surgeon is likely to excise more tissue to remove the margins of the lesion; (2) there is an inherent risk to the patient if all the cancerous tissue is not removed; (3) the surgeon likely will spend time counseling the patient; and (4) often more needs to be done to prevent the cancer from metastasizing further.
 
General surgeons typically make a clinical assessment as to whether a lesion is benign or malignant before excising the lesion. If a malignant lesion is suspected, the general surgeon probably will excise a larger tissue sample in an effort to get at the lesion's margins.
 
Determining how to code the excision, however, is another matter. Marc E. Hernandez, MD, a general surgeon in Inverness, Fla., describes the process (and the problem) as follows:

On occasion, we will see patients to evaluate skin lesions to make an evaluation and recommendations regarding whether they are benign or malignant. Many patients request excision of these lesions.
 
Based on a clinical assessment of whether a lesion is benign or malignant, we perform an appropriate excision. For lesions that clinically appear benign, we in general will make a smaller, more superficial excision with suture closure. For lesions that clinically appear malignant, we make a wider excision with more attention to margins and depth of excision. The specimen is then sent for pathology. The pathology report routinely takes two working days.
 
The question is how to code for the initial excision. Since the extent of excision is based on a clinical diagnosis, one could argue for billing excision of a malignant lesion if the clinical diagnosis and subsequent excision are consistent with a malignant lesion. However, the pathology report sometimes returns two days later with a benign lesion. Because of the delay in the pathology report, one could consider not billing for the lesion as excision of a malignant lesion or a benign lesion until the pathology report returns. However, as I stated earlier, the initial excision was done either conservatively or more aggressively based on the clinical diagnosis.

In the situation outlined by Hernandez, the recommended approach is to wait for the pathology report to return despite the two-day delay, says Arlene Morrow, CPC, a general surgery coding and reimbursement specialist in Tampa, Fla. You have to code to the highest level of specificity and that means waiting for the pathology report " Morrow says.
 
The interests of the patient also mitigate against billing for a malignant lesion excision before the pathology report returns Morrow points out noting that if the lesion turns out to be benign the patient will now have a cancer label and find it difficult if not impossible to obtain health insurance in the future.
 
In addition some carriers want a pre-pathology report indication (i.e. sign or symptom) to provide medical necessity for the lesion excision which in effect means coding all such excisions as benign.

Extra Payment for Wound Repair

Although a general surgeon who suspects that a lesion is malignant and removes a wider margin of tissue will not get paid more for doing so if the pathology report comes back negative he or she will be reimbursed further for the closure says Kathy Mueller RN CPC CCS-P a general surgery coding and reimbursement specialist in Lenzburg Ill.
 
When either benign or malignant excisions are excised (114xx excision benign lesion; 116xx excision malignant lesion) simple repair is considered part of the excision procedure but intermediate (or layered) and complex closures are not and may be billed separately according to CPT and Medicare guidelines. Many surgeons' offices however are unaware that these repairs are billable Mueller says.
 
"As long as the documentation states that the repair included skin and/or subcuticular plus a deeper level an intermediate or complex repair can be billed with the excision of the lesion " Mueller says adding that "there should be two measurements when billing both excision and repair: the size of the lesion before excision and the size of the defect created by the excision. If you wait for the pathology report for lesion size there is usually a decrease in size since tissue shrinks immediately when excised and more when it is put in formalin."
 
For example if a surgeon performs a re-excision of a 2.5 cm squamous cell carcinoma of the shoulder with intermediate repair of a 4.0 cm defect the procedures should be billed using CPT codes 11603 (excision malignant lesion trunk arms or legs; lesion diameter 2.1 to 3.0 cm) and 12032 (layer closure of wounds of scalp axillae trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm). Both procedure codes would be accompanied by ICD-9 code 173.6 (other malignant neoplasm of skin; upper limb including shoulder). No modifier would be needed Mueller says because intermediate repair codes are not bundled into excisions. If the re-excision occurred within 10 days of the first excision however modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be attached to both codes to indicate that the procedures were staged.
 
Mueller adds that when coding re-excisions of malignant lesions the actual size of the original lesion excised needs to be reported. But the repair of the defect created by the re-excision also may be billed because the surgeon usually will take a good margin around the lesion provided the documentation includes the depth of the repair. The sign or symptom that led the surgeon to take a wider margin provides medical necessity for the intermediate repair that is paid separately Mueller says.
 
When excisions and repairs are coded together you should determine which service has more relative value units (RVUs) says Cynthia Thompson CPC a coding and reimbursement specialist with Atlanta-based healthcare consultants Gates Moore & Co. Even though the excision may seem to be more important than the closure it may pay less she says. For example the 11603 is worth 2.95 RVUs while the 12032 pays 3.69 or about 25 percent more. In this case the 12032 should be listed first on the HCFA 1500 claim form Thompson says.

Reimbursement for Benign Lesion Excision

Carriers do not routinely pay for the excision of benign lesions. To be reimbursed the documentation should indicate redness chafing or recent changes in color shape or size. For example carriers likely will recognize the excision of lesions in body areas that tend to be irritated.
 
The removal of other lesions such as moles likely will be considered cosmetic and won't be covered by many carriers. So before excising such lesions physicians should get their patients to sign a waiver to indicate that if the insurance carrier does not cover the procedure the patient will take responsibility for the bill. If the patient is covered by Medicare modifier -GA should be appended to the procedure code to indicate that such a waiver was signed.

Pathology Report Can Identify Missed Procedures

Another useful coding role for the pathology report is to identify services that may have been left out of the surgeon's operative report. For example a surgeon may perform a laparoscopic cholecystectomy (47562) but when the pathology report returns the coder notes that it mentions three skin lesions the surgeon also removed that were omitted from the op report.
 
When that occurs Mueller recommends that surgeons dictate an addendum to the operative note based on the pathology report before the HCFA 1500 claim form is submitted. Otherwise Mueller says "If the carrier ever asks for a copy of the op note you'll be sending in a report that doesn't include all the procedures that were performed."
 
If the surgeon doesn't specify the size of the lesions in the op note not even the pathology report can help and the smallest size lesion code will have to be billed Mueller says. "The excision of three lesions for example can't be coded if the size of the lesion isn't documented in the op note because the lesions are coded by size and there is no documentation in that regard." Lesion sizes can't be deduced from pathology reports because (1) many pathologists describe the size of entire tissue sample examined not just the lesion; and (2) even if the lesion size is documented in the pathology report it will be inaccurate because lesions shrink immediately upon excision and even more while they are being preserved she says.

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