Oncology & Hematology Coding Alert

Wait for the pathology result and get a big boost to your bottom line.

A patient with a past history of skin cancer reports to your office with an actinic keratosis (AK) on his forehead that is approximately 0.7 cm in diameter. Your provider excises the AK and orders pathology testing to determine whether it is malignant.

Eventually, the pathology results show the AK has become a squamous cell carcinoma. They also reveal that the malignant area was showing positive margins, meaning that the procedure did not entirely remove the carcinoma. Your provider calls the patient back into the office and performs a second removal nine days after the original procedure. This time, the pathology report comes back and reveals that the second removal was successful.

How would you go about reporting this? Here’s what our experts had to say.

Code the Initial Excision

First, you’ll need to wait before you code the initial encounter because you do not know the results of the biopsy, and the CPT^® code choice for lesion excision, and the correct ICD-10-CM code for the diagnosis, are partly dependent on whether the lesion is benign or malignant.

As the biopsy results come back positive, “for an excision such as this, you’re looking at 11641 [Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm],” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

But the lesion removal code choice raises some concerns that you must add into your decision making.

Red flag 1: Anatomic location. In this case, you’ll use a code from 11640-11646 rather than a code from 11620-11626 as CPT^® regards the lesion’s location on the forehead as part of the face rather than the scalp.

Red flag 2: Lesion dimensions. You’ll also have to check with your provider that the lesion dimensions given in the note are for the total excision. “The code will only apply if the excised diameter including margins, and not just the diameter of the AK, does not exceed 1.0 cm,” Moore cautions. Anything larger will take a code from 11642-11646.

Red flag 3: Biopsy results. Last, you’ll need to make sure you have the results of the biopsy in hand before billing. That’s because if you results come back negative, you’ll have to code the encounter using 17000 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion). If you do, you’ll be reimbursed the nonfacility fee of $67.34. Using 11641, however, will net you $246 — a whopping difference of almost $180.

Code the Diagnosis

Again, you’ll need to wait for the results of the biopsy to map the procedure code to the correct ICD-10-CM code. If the AK is not malignant, you’ll use L57.0 (Actinic keratosis). Per the guidelines for the code, you’ll also have to use an additional code from W89 (Exposure to man-made visible and ultraviolet light) or W90 (Exposure to other nonionizing radiation), if applicable, to identify the specific form of radiation that caused the AK.

But as the biopsy has revealed the AK is malignant, “the appropriate ICD-10-CM code this time would be C44.329 [Squamous cell carcinoma of skin of other parts of face],” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Red flag 4: “As the anatomic location — the forehead — is a specific location, you should not use C44.320 (Squamous cell carcinoma of skin of unspecified parts of face), which you would only use if your provider has not documented the precise location of the carcinoma on the patient’s face,” Johnson cautions.

Don’t Also Code a Biopsy

In this scenario, the provider performed an excision and sent the resulting excised tissue to pathology for testing. Therefore, you would code the excision, but you may not also report a biopsy for the same procedure and the same lesion.

That’s because CPT^® guidelines preceding the skin biopsy codes state that obtaining tissue for pathology during an integumentary procedure, such as excision, destruction, or shave removals, is a routine component of such procedures and not separately reported. Per CPT^® guidelines, “The use of a biopsy procedure code (eg, 11102, 11103, 11104, 11105, 11106, 11107) indicates that the procedure to obtain tissue solely for diagnostic histopathologic examination was performed independently or was unrelated or distinct from other procedures/services provided at that time.”