Oncology & Hematology Coding Alert

Warning: You may lose up to $75 per procedure for any erroneous reporting.

Whenever the oncologist sees a patient for skin or skin structure cancer lesions, reporting accuracy of any biopsy may be simple, however can add up to huge loss if you miss out on reporting them. Here are answers for the top four most frequently asked questions about site-specific integumentary biopsies from theexperts.

Q1: What’s the difference between an excision and a biopsy?  

A: Simply put, when the physician intends to fully remove a lesion, he performs an excision. If the goal is just to take a sample of the lesion for pathology, a biopsy is performed.

Report a biopsy with CPT^® code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). Report any separate additional biopsies with +11101 (…each separate/additional lesion [List separately in addition to code for primary procedure]). “Additionally, the location of each biopsy should be clearly supported by documentation,” says Kelly  C.  Loya,  CPC-I,  CHC,  CPhT,  CRMA, Associate Partner of Pinnacle Enterprise Risk Consulting Services, LLC. “Often the physician will draw a picture of the location in the handwritten notes. In EMR, this can be a challenge, so a clear verbal description should be evident.”

If the removal was an excision, the CPT^® code chosen will depend on the size of the lesion, where it is located, and whether the lesion is malignant or benign. Report excision of benign lesions with a code from the 11400-11446 (Excision, benign lesion…) range or assign a code from the 11600-11646 (Excision, malignant lesion including margins…) range for malignant lesions.

Don’t miss: Shave removals are another common source of confusion, says Pamela  Biffle,  CPC,  CPC-P,  CPC-I,  CCS-P,  CHCC,  CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. Report shave removals with CPT^® codes 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…). “Remember shave excisions are a technique for removal of a lesion and should not be confused with a biopsy, which is done only to determine the nature of the lesion. Depending on the size of the lesion a biopsy, may incidentally, but is NOT intended to remove the lesion fully,” Loya says.

Q2: When should I report a site-specific biopsy code instead of 11100?

A:  Any time there is a code that describes the specific site of the biopsy, report the more specific biopsy code. The 11100 code definition states “unless otherwise listed.” That means you should not use 11100 if the skin biopsy was taken from a specific site listed elsewhere in CPT^®.

The more specific code would allow greater reimbursement for the higher level of complexity for site-specific procedures. The practice is losing income if the coding doesn’t reflect these site-specific codes. Errors can occur if you aren’t watching because skin coding practices rely on the integumentary section of the CPT^® manual.

Example: A patient presents to your practice with a papular lesion of the lip. After your physician has examined 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 your physician notes the site-specific biopsy in the documentation, correct coding of the service would generate $25 more for the procedure performed on the lip than if you had reported 11100 because this biopsy required more work or skill of the physician.

Medicare assigns 3.68 non-facility relative value units (RVUs) to 40490, when multiplied by the 2018 $35.9996 conversion factor, leads to $132.48 in reimbursement. Compare this to $108.00 for 11100 (3.00 RVUs). Often, oncologists take extra steps in a biopsy of the lip, including the use of a chalazion clamp to control bleeding.

Q3: What are some of the site-specific skin biopsy codes I should keep an eye out for?

A: Listed below are common ones, along with the Medicare Physician Fee Schedule non-adjusted payment if performed outside of a facility (based on RVUs multiplied by the conversion factor). Note that all of these site-specific codes are valued higher than 11100’s reimbursement of $108.00.

• 11755 (Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)) [$135.00]
• 30100 (Biopsy, intranasal) [$141.48]
• 40490 (Biopsy of lip) [$132.48]
• 40808 (Biopsy, vestibule of mouth) [$192.60]
• 54100 (Biopsy of penis; (separate procedure)) [$205.56]
• 67810 (Incisional biopsy of eyelid skin including lid margin) [$176.04].

Q4: Should I wait for the path report to choose what code toreport?

A: The pathology report would not change which biopsy code you report; however, it could change if an excision was performed. The pathology report will also help determine the diagnosis (ICD-10-CM) code to report when acknowledged by the treating physician. Therefore, for a complete, accurate claim, it is wise to wait for the pathology determination, Biffle advises: “It can change the code reported. For example, you think a benign lesion was excised but the path came back malignant.”