Orthopedic Coding Alert

Example 2 reveals why you need to watch for the narrowest margin.

When patients with lesions report for treatment, you’ll need to answer several questions to submit a spot-on claim. To properly report lesion removals, you need to know the lesion type, the body area and the excised area’s exact measurement. Getting just one of these wrong can result in a miscoded claim and a denial.

Follow this expert advice to choose the proper lesion excision code for each encounter.

1. Determine Lesion Type First

On your lesion excision claims, you should know whether the physician removed a benign or malignant lesion from the patient. When reporting lesion excision, choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions, he says.

You need the pathology report to know whether the excised lesion was benign or malignant.

2. CPT® Breaks Body Into 3 Areas

Once you confirm whether the lesion is benign or malignant, you should narrow your code choice further based on which body area the surgeon operated on. For coding purposes, CPT^® breaks lesion removal codes into three body areas:

• trunk, arms, legs (11400-11406, 11600-11606)
• scalp, neck, hands, feet, genitalia (11420-11426, 11620-11626)
• face, ears, eyelids, nose, lips, mucous membrane (11440-11446, 11640-11646).

3. Include Margins on Lesion Measurements

Once you have discovered the lesion type and location, you’re ready to record the lesion’s exact measurement for reporting purposes. When calculating lesion size, don’t just measure the lesion. Be sure to report the total excised diameter on the claim.

As discussed in the case study on page 18, to determine the appropriate lesion excision size, you should measure the lesion’s widest diameter point, and then add double the width of the narrowest margin.

Example 1: The physician excises a benign lesion from a patient’s left shoulder. The lesion measures 1.5 cm at its widest. To ensure removal of all malignancy, the physician allows a margin of at least 1.5 cm on all sides.

In this case, add the size of the lesion (1.5 cm) and double the width of the narrowest margin (1.5 cm x 2 = 3 cm) for a total of 4.5 cm (1.5 + 3 = 4.5).

The appropriate code in this case is 11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter over 4.0 cm).

Example 2: The physician excises a benign lesion from just below the patient’s right shoulder. The lesion measures 2 cm at its widest. To ensure removal of all malignancy, the physician allows a margin of at least 1.5 cm on all sides. In addition, the physician slightly lengthens the margins at two ends to allow the wound to heal with a less obvious scar.

To calculate the excised diameter, you should begin with the size of the lesion (2 cm) and add the width of the narrowest margin multiplied by 2 (1.5 x 2, or 3 cm total) for a total of 5 cm (2 + 3 = 5). In this case, you should also report 11406.

Tip: You may report intermediate (12031-12057) or complex (13100-13153) closure separately from the removal code, according to CPT^® guidelines. But your payer may have different rules, so check first.