Oncology & Hematology Coding Alert

Attention, surgical oncology coders: Get out your scissors, glue and rulers, because CPT 2003 contains significant revisions to the excision guidelines for lesions. In addition, the volume contains a misprinted page with a corrected supplement to insert.

Not with standing the printing glitch, more consistent terminology in the guidelines signals that CPT 2003 is evolving into the resource that the AMA CPT Editorial Panel has been promising, says David Davis, CPC, CEO of Infinity Reimbursement and Research in Alpharetta, Ga.

Clear, consistent guideline changes for lesion excision both benign and malignant will have a measurable impact on surgical oncology practices. For starters, excision of benign lesions now explicitly includes neoplasms in the CPT text. Choose a diagnostic code from the 210.x to 229.x (Neoplasm, benign) series. Malignant lesions get detailed as basal cell carcinoma (M8090/3), squamous cell carcinoma (M8070/3), and melanomas (172.9, for example).

Code selection is no longer based on lesion diameter but on excision diameter, says Patricia Wildman, RHIA, clinical reimbursement auditor for the Children's Hospital Boston. Excision now includes the margins of each lesion.

CPT instructs coders to make their selections "by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision." The margins are further defined as "the most narrow margin required to adequately excise the lesion, based on the physician's judgment."

Margin size will vary by individual. For example, a 1.0-cm melanoma on the back may have a 2.0-cm margin on either side, resulting in an excised diameter (lesion plus margins) of 5.0 cm (1.0 cm + 2.0 cm + 2.0 cm). Such a lesion should be coded 11606 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm).

At the same time, a 0.9-cm melanoma on the nose may have a 0.3-cm margin above and below it, resulting in an excised diameter (lesion plus margins) of 1.5 cm (0.9 cm + 0.6 cm). Correct coding for this lesion would be 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm).

Coders should always get measurement information from the surgeon's notes, and that shouldn't be a problem because surgeons routinely chart this information, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans. "Note that the size of the excised lesion should be the size before removal, not as measured by the pathologist."

However, for correct coding and proper reimbursement, it will be important for the physician to document in the operative notes either the total excised diameter or the lesion size along with the skin margin size so the coder can determine the correct excised diameter. If practices choose the latter option, Wildman says, a diagram or template created by the surgeon may be an easy way to keep your margins clear.

The physician should measure and annotate the lesion plus margin prior to excising it and should report each malignant lesion separately.

These revised guidelines apply to codes ranging from 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less) to 11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm).

The code range 11600-11646 includes simple closure, Davis says. Prior to this update, "if one were coding simple closure separately (without any lesions), one would code the length of the wound site, not the lesion," he says. Now the repair site is identical, in terms of length, for simple or complex repair, which allows the physician to report the work that was actually performed.