General Surgery Coding Alert

Question: I'm confused about the rules for coding wound repair with lesion removal. What codes should I report if the surgeon removes four lesions from the patient's right leg?. The sizes are 0.5 cm, benign with complex repair; 0.5 cm, malignant with complex repair; 1.5 cm, benign with simple repair; and 2.0 cm, benign with complex repair.


Illinois Subscriber

Answer: In many cases, lesion excision will include closure, depending on the level of repair required.

Excision codes 11400-11446 (benign) and 11600-11646 (malignant) describe full-thickness (that is, through-the-dermis) lesion removal with margins and include simple (non-layered) closures (CPT 12001-12018). As noted in CPT, however, "The closure of defects created by incision, excision or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately."

But even this is not a hard-and-fast rule - at least for Medicare and other payers who follow the National Correct Coding Initiative (NCCI). For these payers, intermediate (12031-12057) or complex (13100-13152) repairs are bundled by NCCI to excisions of benign lesions of 0.5 cm or less (11400, 11420 and 11440), presumably because even complex repair of such a small wound does not increase physician effort considerably.
 
In your case, you cannot claim separate closure for the first lesion because it is 0.5 cm or less (and therefore bundled by NCCI). You may claim separate closure for the second excision, even though it is 0.5 cm or less, because it is malignant rather than benign. Do not report a separate repair code for the third excision, because simple repair is always bundled. You may report complex repair separately with the final excision because the benign lesion measured greater than 0.5 cm.