General Surgery Coding Alert

Question: The surgeon excised two benign lesions of about the same size (roughly 0.8 cm) from the patient's vulva. They only required a simple suture. How should I report the two excisions?

Ohio Subscriber

Answer: You should separately report each lesion the physician excised, according to CPT. In this case, you have two options for reporting this service. First, you can submit 11421 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm) and 11421-51 (Multiple procedures).
 
Alternatively, you can use 11421 and place a "2" in the units box of the CMS 1500 claim form. Be sure to ask your payer which way it prefers you to submit this claim, because come carriers do not recognize modifier -51 or have software that automatically adds the modifier to multiple-procedure claims.