Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist removed six lesions from a patient's right upper eyelid in February. In March, he removed six more -- three from the right lower eyelid and three from the left upper eyelid. All of the lesions were less than 0.5 cm in diameter. What is the proper way to code this?

Illinois Subscriber

Answer: You may code and bill for all 12 lesions. Report one unit of 11440 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) for each lesion, no matter when the ophthalmologist removes them -- or which eyelid he removes them from.

The real challenge in coding multiple lesion removals, however, is determining which modifier to append. Some carriers want you to use modifier 51 (Multiple procedures), although most Medicare carriers will automatically append it for you. Other carriers want the eyelid modifiers E1-E4. And some want both. Ask your carrier for its modifier policy.

Watch out: You cannot add up the lesions to arrive at a larger size. For example, if your ophthalmologist removes two lesions, both under 0.5 cm in diameter, you cannot code 11441 (... excised diameter 0.6 to 1.0 cm) simply by adding the sizes together. Instead, you should report the procedures on separate lines using 11440 twice with the appropriate modifiers.

Key: Here is where good documentation pays off -- always make sure the size and location of all lesions are reported in the medical record. A detailed and labeled drawing showing lesion size and location is an optimal method of documentation along with a narrative summary of the procedure.