Otolaryngology Coding Alert

Excision includes simple closure only

If you don't read down to the last line of lesion excision reports, you could cost your practice big bucks.
 
Take a look at the following skin nevus excision report and see how many billable procedures you can identify:

Preoperative diagnosis: Right facial skin nevus.

Postoperative diagnosis: Right facial skin nevus.

Name of operation: Excision of skin nevus.

Description of operative procedure: A nurse brings the patient into the operating room and places him in the supine position. After the otolaryngologist obtains an adequate plane of oral endotracheal anesthesia, the small 3- to 4-millimeter raised nevus was excised with a fusiform excision in the posterior portion of the right cheek. He closes the fusiform excision in layers using 4-0 chromic and 6-0 black nylon. The patient tolerates the procedure. The nurse returns him to the recovery room in satisfactory condition.

The Challenge

Coders aren't sure whether they should report 11440 (Excision, other benign lesion including margins [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) for the nevus procedure. For instance, a California subscriber feels that Medicare's $93.82 rate does not adequately capture the procedure's complexity. "Should I report a different code, or am I missing a billable charge?" she asks.

The Solution

Since the otolaryngologist documents the lesion size but does not include any margins, you should report only 11440 for the nevus excision, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee.

But because the otolaryngologist uses layered closure, you should also report the repair with 12051* (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), Borden says.

Remember: 11440 includes simple closure, not intermediate closure, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Omitting the procedure will cut 4.04 relative value units ($148.63) from the claim.

The closure contains more relative value units (4.04) than the excision (2.55 RVUs). So, you should report the higher-valued procedure - the closure (12051) - and then the excision (11440) appended with modifier -51 (Multiple procedures) to indicate that the excision is a multiple procedure. Due to multiple-procedure rules, most payers will pay 11440-51 at 50 percent, meaning you will capture an additional 2.76 RVUs ($101.54) for reporting the closure (12051).