Medicare Compliance & Reimbursement

Discover why lesion excisions don't need to add up. Myth: When you excise multiple lesions, you should add their areas together and bill for one excision.
 
Fact: This is a "common misconception," according to an article in the August 2000 CPT Assistant. In fact, you should bill for each lesion separately, using the 59 modifier.

The only exception is if the doctor excises two lesions close together, using only one excision.

Some coders, especially ones who don't do integumentary coding very often, become confused because the rules are different for laceration repairs, notes Joan Gilhooly, president of Medical Business Resources in Evanston, IL. With laceration repairs, you do add the lengths of tissue repaired and bill one code, she notes.

With lesion excision, you should calculate the size of the excision by measuring the size of the lesion plus the size of the margins necessary to ensure a clean margin, Gilhooly notes. So with a single excision that removes two separate lesions, you would include the space in between them inside a clean margin.

Clarification: This isn't really the same as "adding" the two lesions together, she adds. It's just using the rule of the size of the lesion plus the size of the margin.

You should almost never bill for two lesions using one code, adds Christine Liles, insurance supervisor with Knoxville Dermatology Group in Knoxville, TN. She encourages her doctors to remove each lesion separately and code it separately; then she can add the closure together since it's on the same anatomical site.

Watch out: Some private payors have different policies, notes Detroit podiatrist Craig Gastwirth. Payors may require you to combine the sizes of the lesions and code for that combined area, he notes. Blue Cross Blue Shield of Michigan has this policy and has published it in its provider bulletin, he adds.

"This is a ridiculous policy," Gastwirth adds, but the payor can make its own rules. So you should be sure to check your non-Medicare payors' Web sites and bulletins for their policies. And keep an eye open for denials from payors that use a combined-lesion policy.