Internal Medicine Coding Alert

"Internists are dealing with straightforward integumentary complaints that were once readily referred to dermatologists and this includes wart removal. But all too often internists perform wart removal procedures without differentiating between wart types and without knowing that those differences can have a big effect on their rightful reimbursement. As well, coders who arent alert to the subtleties of coding terminology may be prolonging or perpetuating the misapprehension.

Understanding Wart Removal Codes

The problem rests in a misunderstanding of the relevant CPT codes, says Kathy Pride, CPC, coding supervisor for the Martin Memorial Medical Group, a 57-physician group practice in Stuart, Fla. When internists and coders look for a wart removal code, many of them only see 17110 [destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions] or 17111 [ 15 or more lesions].

However, using 17110 and 17111 often leads to underbilling because reimbursement is the same (1.69 relative value units [RVUs] for 17110) for removing one wart as it is for 14 warts, while the single-claim RVU for 17111 is 2.11 for 15 or more warts, regardless of whether its 15 or 50 warts.

In Florida, Medicare pays $61.19 for 17110, Pride says. Internists and coders should be aware that there is another coding option for common and plantar warts that isnt so obvious in the CPT manual and that pays significantly more.

In my experience, Ive found that many internists fail to understand the importance of diagnosing different types of warts, she says. Typically, theyll ask, Theres a difference? But when an internist learns to differentiate common and plantar warts from flat warts, theres a big difference in payment.

Read Code Descriptors Carefully

Pride points out that the destruction of common warts should be coded 17000 (destruction by any method, including laser, with or without surgical curettement, all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions, including local anesthesia; first lesion) and 17003 ( second through 14 lesions, each [List separately in addition to code for first lesion]).

The word wart does not appear in the descriptor for these codes and I believe thats the main reason why so many internists and coders fail to use them properly, Pride says. You have to look at the guidelines under Destruction (page 56 in CPT 2001), just before the description for the 17000 series of codes to see that they apply not only to various lesions but also to warts.
The words in parentheses after the description for 17111 state, For destruction of common or plantar warts, see 17000, 17003, 17004. So, until you do a little detective work, its not obvious that the correct way to bill for the destruction of common warts is to use 17000 and 17003, Pride says.

Note: Never use 17003 by itself. It must be used with 17000. Also, do not report 17004 ( 15 or more lesions) with 17000-17003. Code 17004 is always reported independently.

Reimbursement Can Double

Putting the 17000 series codes to work makes a big difference in reimbursement. For example, if a patient presents with eight common warts on the back of one hand, the internist can code 17000 (1 unit, 1.67 RVUs) for the first wart, and 17003 (7 units, 0.39 RVUs each) for the remaining warts.

In Florida, Medicare pays $60.15 for 17000 and $14.63 for each unit of 17003, Pride says. Using the example of eight common warts, the reimbursement would be $60.15 for the first wart, plus 7 x $14.63 for the remaining seven warts, for a total of $162.56.

By comparison, reporting 17110 for the removal of the same eight warts, an internist would be reimbursed for one removal, or $61.19. So using the 17000 and 17003 codes allows for an increased reimbursement of more than $100. If the internist removes 15 or more warts, reporting 17004 (5.37 RVUs) would pay about $195. Payment varies from carrier to carrier and region to region.

Identifying Warts

Common warts begin as smooth, flesh-colored papules and evolve into dome-shaped gray-brown growths with black dots on the surface. By comparison, flat warts are pink, light brown or light yellow and are slightly elevated, flat-topped papules that vary in size from 0.1 to 0.3 centimeters in diameter.

John Wiedner, MD, an independent internist in Grover, Mo., regularly performs wart removal procedures and says he was surprised to learn about the alternative codes that increase reimbursement for common and plantar wart removal.

Ive always just focused on removing the warts in the best way possible, not on how they were coded, he says. I knew there were different types of warts, but Id thought they were all coded the same.

Id always used the 17110/17111 series for all warts. I think I must be typical of a lot of physicians who do wart removal. We focus on technique and not on coding. Ill certainly document them by case and make sure my staff is familiar with all the wart codes.

Coding by Method of Removal

Scenario #1: An established 60-year-old male patient presents for a scheduled E/M visit to check on high blood-sugar levels for his diabetes. During the examination, the patient mentions some irritation around his waistband. The internist finds seven common warts in the area and advises removal immediately. The patient agrees and the internist initiates a cryosurgical (liquid nitrogen) procedure.

The physician is performing an expanded problem-focused history and exam, and the medical decision-making is of moderate complexity related to the diabetes, Pride says. This visit should be coded using 99213 (office or other outpatient visit for the evaluation and management of an established patient. Physicians typically spend 15 minutes face-to-face with the patient) with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached. The appropriate diagnosis code for the E/M visit would be 250.02 (diabetes, uncontrolled).

The wart removal would be reported with 17000 and 17003 x 6 for the additional six warts with diagnosis code 078.10 (viral warts, unspecified).

Same-visit Common and Flat Wart Removal

Scenario #2: A new 45-year-old female patient presents with an earache. The internist performs a detailed history and expanded problem-focused exam, and the medical decision-making is of moderate complexity.

The internist determines the patient has an infection in her right ear and prescribes an antibiotic. During the examination the internist notices three common warts behind the patients right ear, and five more behind the left ear. The internist asks the patient if she wants them removed by cryosurgery. She agrees, but also indicates she has more warts on her forehead, hidden behind her bangs. The internist finds a cluster of 27 small flat warts and suggests treatment of these be started with tretinoin cream.
According to Pride, the proper coding in this example is 99202 (office or other outpatient visit for the evaluation and management of a new patient. Physicians typically spend 20 minutes face-to-face with the patient) with modifier -25 attached. A corresponding diagnosis code of 382.00 (otitis media) would be used for the E/M service.

Coders would report 17000 for the first common wart with a diagnosis of 078.10, and 17003 x 7 for the additional seven warts, Pride says. The treatment of the flat warts on the forehead is inclusive of the E/M code because only a topical cream was prescribed. A surgical treatment was not performed on the flat warts.

Coding Alternative Removal Methods

Physicians sometimes treat warts with cream, but this method of treatment does not fall under the description for wart removal codes, which only includes electrosurgery, cryosurgery, laser and chemical treatment. As Pride indicates, treatment for wart removal with creams is part of an E/M visit.

A variation of scenario #2 illustrates another possibility: Instead of tretinoin cream, the internist treats the 27 flat warts with salicylic acid. The E/M code would still be 99202 with modifier -25 attached, the removal of the common warts would still be 17000 (1 unit) and 17003 x 7, but using salicylic acid to remove the flat warts would be reported with 17111 for 15 or more lesions (warts).

A variation of scenario #2 again illustrates another coding possibility: Suppose the first salicylic acid treatment isnt totally effective on the flat warts and the patient returns within the 10-day global period for a follow-up visit and the internist applies more acid on the flat warts.

This is a situation where modifier -58 (staged or related procedure or service by the same physician during the postoperative period) would apply, Pride says. It should be coded 17111-58. Further, the internist should attach to the claim written documentation of what was involved. In this case, state that the first salicylic acid treatment wasnt effective and that a second treatment was necessary.

Pride points out that if the patient came in for a second treatment after the 10-day global period, the coding would be 17111 without the modifier because the treatment was done outside of the global period.

If in Doubt, Query the Internist

Coders should stress to their internists the importance of distinguishing the types of warts being removed and the procedures/methods involved. If internists dont supply this information, coders should ask them to document clearly all relevant details in the patients chart.

Flat warts, particularly, may be resistant to treatment and may need repeat procedures. However, there doesnt appear to be any problem with Medicare or commercial carriers in this regard. Ive never experienced claims for wart removal being denied because the treatment had to be performed again, Pride says.

Although some payers, including Medicare, may require documentation of medical necessity for wart removal, our sources for this story, Pride and Wiedner, have never encountered denials. Ive experienced some carriers getting sticky about removing moles, but claims for wart removal have never been a problem, Wiedner says."