Medicare Compliance & Reimbursement

If you automatically assign 11100 when your physician specifies a patient's biopsy site, you could be forfeiting reimbursement that your practice deserves. Using CPT's site-specific codes can dramatically increase your coding accuracy. Plus, they pay more than the most widely used code, 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [includingsimple closure], unless otherwise listed; single lesion).

Site-specific biopsy codes tell the payer that the physician performed a biopsy at a specific location, rather than a generic integumentary based biopsy (11000). A site-specific biopsy code also represents a more complicated procedure than 11000 does.

Result: The doctor deserves more pay for the higher level of complexity of these site-specific procedures. Your practice is losing income if your physicians overlook these site specific codes, which is easy to do because medical practices rely on the integumentary section of the CPT manual.

Tip: If the doctors in your practice often forget that there are site-specific biopsy codes, you can help them remember by including a list of the site-specific biopsies on your encounter form to jog their memory.

Example 1: A patient presents to your practice with a papular lesion of the lip. After the physician examines the patient, he determines that he must perform a biopsy.

In this scenario, you should report 40490 (Biopsy of lip) instead of 11100. As long as the physician notes the sitespecific biopsy in the documentation, you should receive approximately $25 more for the procedure on the patient's lip than if you had reported 11100 because this biopsy required more work from the dermatologist, notes Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education in Watauga, Texas. Medicare assigns 3.35 nonfacility relative value units (RVUs) to 40490, which, multiplied by the $36.0846 conversionfactor, leads to $120.88 in reimbursement.

Compare this to $95.26 for 11100 (2.64 RVUs). Often, physicians take extra steps in a biopsy of the lip, including the use of a chalazion clamp to control bleeding.

Example 2: A patient with a pigmented lesion of the nail bed presents to your practice. The dermatologist suspects trauma but feels he should perform a nail bed biopsy to rule out melanoma. Your first thought in coding this scenario might be to bill 11100. But you should instead bill 11755 (Biopsy of nail unit [e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds]). Code 11755 is more accurate and also pays approximately $25 more than code 11100 (3.35 non-facility RVUs x $36.0846 = $120.88), says Biffle. When a dermatologist performs a nail bed biopsy, he cuts through the plate, biopsies the nail bed, and may suture the wound. This process is much more complicated than a typical skin biopsy.

When your physician performs multiple biopsies, you need a tool to unlock the claim's payment. Clarify the circumstances to the payer using modifiers.

Example: The physician performs a biopsy of a lesion on a patient's arm. He performs another biopsy on the patient's eyelid during the same visit.

Solution: Because your physician specifies the site in the detailed documentation, you can see that the documentation justifies reporting 11100 for the biopsy on the patient's arm and 67810 (Biopsy of eyelid) for the second biopsy.

You should always wait until the pathology report comes back to choose the proper codes to report, even though this will not always affect the CPT code you will wind up choosing. Instead, waiting for the path report reflects good business practice -- and correct coding from a diagnosis coding standpoint.

The biopsy specimen's pathology will affect the ICD- 9 code you report, but most CPT procedure codes are not based on the specimen's results. "There are a few CPT codes which are linked to specific diagnoses (for instance, excision of benign and malignant lesions), but overall CPT is about what you did; ICD-9 is about the outcome or the reason for it," explains Marcella Bucknam, CPC, CCSP, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.