Ophthalmology and Optometry Coding Alert

When a pathology report shows a patient has a single benign lesion that was excised from the eyelid, the coding is straightforward. Use 67840* (excision of lesion of eyelid [except chalazion] without closure or with simple direct closure). This pays much better (double the fee) than 11440 (excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less) because it takes into account the extra work involved with surgery on an eyelid, due to the proximity to the eye.

There are times, however, when it makes more sense to bill 11440 or other codes in that series 11441 (lesion diameter 0.6 to 1.0 cm), 11442 (lesion diameter 1.1 to 2.0 cm), 11443 (lesion diameter 2.1 to 3.0 cm), 11444 (lesion diameter 3.1 to 4.0 cm) or 11446 (lesion diameter over 4.0 cm). You should use the 1144x series when there are multiple lesions. Note that there is no size requirement for 67840* which can adversely affect your reimbursement if you are removing several large lesions. Thats why its important for ophthalmologists to take into account the size as well as the number of lesions.

But rule number one is that you check with your payers to find out which modifiers they require when billing multiple lesion excisions. You will likely either need to use modifier -51 (multiple procedures) or the eyelid modifiers (-E1 for upper left, -E2 for lower left, -E3 for upper right, and -E4 for lower right), explains Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology and based in Santa Barbara, Calif. Some payers will even want both -51 and the eye modifiers.

And rule number two something many ophthalmology coders forget is that you cannot add up the lesions to arrive at a larger size, says Sharron Stevens, CPC, CCS-P, coding and reimbursement specialist for East Tennessee State University in Johnson City. For example, if you remove two lesions, both under 0.5 cm in diameter, you cannot code a 11441 simply by adding the sizes together. Never add them up, says Stevens. Put them on separate lines using the eyelid modifiers.

Because lesions can be very misleading on visual examination as to the nature of the cells, it is always advisable to wait for the pathology report before billing the excision, says Lise Roberts, vice president of Health Care Compliance Strategies, a compliance and coding consulting company based in Jericho, N.Y. It is an advantage to use the malignant lesion codes (11640-11646) when appropriate because the reimbursement is higher, says Roberts. Also the ophthalmologic-specific codes for excision and repair of eyelid that involves the lid margin (67961 for up to one-fourth of lid margin or 67966 for over one-fourth of lid margin) pay the best, so the location, lesion size and work done in excising the lesion should be well documented.

Note: Lesion excision and/or repair codes are not for use with skin tags. There are separate codes for skin tag removal (11200-11201).

The following hypothetical scenarios will help illustrate correct coding for lesion excisions:

Scenario #1: A patient has three benign lesions removed one from the upper left eyelid, one from the lower left eyelid, and one from the upper right eyelid. Correct coding for a payer requiring both modifiers is 67840-E1, 67840-51-E2 and 67840-51-E3. You should not use units with 67840, says Duran. It would be a billing similar to that for punctal plugs. Since you are coding 67840, the size of the lesions doesnt matter.

Tip: Code 67840* is a starred procedure, which means that you can bill for an evaluation and management (E/M) service as well, providing that you append modifier -25 to it and document a separate and distinct service from the lesion removal.)

Scenario #2: Patient has three benign lesions removed. All three are from the upper right eyelid, and all are less than 0.5 cm in diameter. There are three different possible solutions to this problem.

1) Use 11440 with a three in the units field, says Margaret Mac, CMM, CPC, an administrator at Florida Eye Center in St. Petersburg, Fla. But bear in mind, theyll cut it down and only pay you for what they want anyway. Macs solution is to make sure each excision is well documented in the notes. I have the physician make a drawing and say what the exact sizes are, and I attach that paper to the claim, she says. But I still have problems with Medicare.

2) Stevens recommends appending the modifier -59 (distinct procedural service) on each of the subsequent 11440 codes. Medicare will do a reduction anyway, so you dont need to worry about the modifier -51 (multiple procedures), Stevens says. But if you want to try to get paid for multiple excisions on the same lid, modifier -59 may work.

3) The third solution, recommended by Lamon Willis, CPC, a coding consultant in Lawtey, Fla., is to just bill for the 67840*, regardless of the number of lesions excised from one eyelid.