General Surgery Coding Alert

Actinic keratosis dx gives a clue to malignant status

Beginning Jan. 1, you can choose CPT codes to distinguish between destruction of premalignant and benign lesions.

CPT 2007 has revised the descriptors for 17000-17004 to make them apply only to premalignant lesions, states the AMA's CPT Changes 2007: An Insider's View. Similarly, you should now reserve 17110 and 17111 for benign lesions other than skin tags or cutaneous vascular proliferate lesions, as follows:

- 17000 -- Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion

- +17003 -- - second through 14 lesions, each (list separately in addition to code for first lesion)

- 17004 -- Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions

- 17110 -- Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions

- 17111 -- - 15 or more lesions.

Use Caution When Assigning Units

Guidelines for assigning code units for premalignant and benign lesions differ, so be sure you read the code descriptors carefully.

-You should report a single unit of 17000 for the first premalignant lesion the physician destroys,- said Daniel Mark Siegal, MD, MS, during a Nov. 16, 2006, presentation at the AMA CPT and RBRVS 2007 Annual Symposium in Chicago. -You would then apply a single unit of 17003 for each of the second through 14th lesions.

-If the physician removes 15 or more lesions, report only 17004. You would never report 17000 and 17004 or 17003 and 17004 during the same session,- he said.

Example 1: The surgeon destroys 13 premalignant lesions. In this case you would report 17000 (for the initial lesions) and 17003 x 12 (one unit each for each for the 12 additional lesions).

Example 2: The surgeon destroys 19 premalignant lesions. In this case you would report 17004 only.

When reporting destruction of benign lesions, you should report 17110 for up to 14 lesions or 17111 for 15 or more lesions.

-On a given patient on a given day, you should choose either 17110 or 17111, never both,- Siegal said.

Example 3: The surgeon destroys five benign lesions. In this case, you will report 17110.

Example 4: The surgeon destroys 22 benign lesions. here, you should report 17111. You would not report 17110 in addition to 17111, and you should never report multiple units of 17111.

Size doesn't matter: When assigning codes for benign or premalignant lesions, only the number of lesions, not the lesion size, matters.

-Destruction of 10 big lesions codes out the same as destruction of 10 small lesions,- Siegal said.

You Can Mix and Match, When Necessary

You can report destruction of both benign and premalignant lesions for the same patient during the same session, when documentation supports such coding.

Example: The surgeon destroys 12 premalignant lesions and six benign lesions during the same session. In this case, you would report 17000 (for the first premalignant lesion) and 17003 x 11 (for each of the additional 11 premalignant lesions), as well as 17110 (for the six benign lesions).

Code 17110 -covers up to 14 lesions,- Siegal said.

702.0 Required ICD-9 With 17000-17004

You should always expect to see a diagnosis of 702.0 (Actinic keratosis) with any premalignant lesion destruction codes 17000-17004, Siegal said. If a 702.0 diagnosis is justified and supported by documentation, all payers should agree that treatment is medically necessary and reasonable.

The number of diagnoses that may accompany benign lesion destruction codes 17110 and 17111 is  more numerous and can include, for instance, 216.x (Benign skin lesions), 702.1x (seborrheic keratosis) and 078.1x (Warts), among others. Note, however, that payers may not recognize medical necessity for all benign lesion destructions.

-Something like genital warts (078.11) can be a public-health nightmare, as they can be malignant precursors,- Siegal said.

On the other hand, destruction of a facial scar (which is technically a benign lesion) -- which may be important to the patient -- would probably not pass a medical-necessity test for the payer.

Bottom line: You might want to check with your payer prior to performing any destruction of a benign lesion to see if the procedure meets medical-necessity requirements and thereby warrants coverage.