Otolaryngology Coding Alert

Discover if your responses to scenarios 1-3 are spoton, or if you need to dig deeper into lesion excision coding concepts.

Important: "You always need to have the site of the lesion or tumor as well as the excision size including all the margins," Rhonda Hardison, CPC, clinical quality coding coordinator for Lake Physician Group in Baton Rouge, La.

"If the physician doesn't give you this information, he or she needs to make an addendum to his procedure note." Also, "save yourself time and money by waiting for the path report to come back before you bill your excision code. Excisions of malignant lesions pay more than excisions of benign ones," says Fariba Nesary, CPC, billing supervisor at University ENT in Albany, N.Y.

Scenario 1: A family physician (FP) refers a patient to your ENT for excision of a "mole" on the patient's left cheek. The ENT suspects that the mole is a small basal cell carcinoma (which is later confirmed by pathology).

She performs an excision to remove the lesion, which measures 0.9 cm with margins, in the office. She then closes the wound via simple repair and releases the patient.

Solution: In this case, you would report the excision alone (11641, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm), says Amanda Kunze, CPC, OCS, reimbursement specialist for the Eye & Ear Clinic in Wenatchee, Wash. You would include a diagnosis of 195.0 (Malignant neoplasm of head, face, and neck).

Watch out: All procedures include a minimal E/M, so unless the ENT can provide documentation for a significant, separately identifiable E/M service above and beyond that usually included in the excision, you are limited to reporting the excision only.

Scenario 2: The FP refers the patient to the ENT for a skin lesion removal from the forehead. This time, however, the ENT views the lesion as potentially more serious and not diagnosable by simple exam. The ENT performs a thorough exam and biopsy to determine the nature of the lesion. The biopsy returns positive for malignancy, and the ENT schedules the patient for excision at a later date in the operating room (OR).

Solution: First, you should report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), says Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist for UC Health Ear, Nose and Throat in Cincinnati, Ohio. Your diagnosis for this stage is 709.9 (Unspecified disorder of skin and subcutaneous tissue).

In this case, if the ENT documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...), Nesary says.

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to distinguish the E/M service as significantly above that included with the biopsy, Hardison says.

On the later date of the excision, you will report the excision (for instance, 11644, ... excised diameter 3.1 to 4.0 cm), as well as any allowable wound repair (such as 12052, Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm). Had the closure involved only a simple closure, you would not have reported the closure, as payers consider simple closures inclusive to lesion excisions.

Scenario 3: The ENT suspects squamous cell carcinoma on the cheek and excises the lesion in the office. The pathology report returns later showing positive margins -- meaning that the ENT did not remove all the malignancy and must excise additional tissue. The ENT schedules an additional excision for wider margins in the OR and takes a frozen section. This time the pathology report returns negative.

Solution: Report the initial excision (for example, 11642), as well as any allowable wound repair and E/M services (if appropriate) that the ENT provides in his office. For the additional excision on a later day in the OR, report another excision code as appropriate to the size of the tissue removed (for example, 11643, ... excised diameter 2.1 to 3.0 cm), as well as any allowable wound repair.

If the re-excision took place during the initial procedure's (11642) global period (within 10 days of the initial procedure), you must append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the lesion excision code, Nesary says.

The ENT will want to excise all malignant tissue on the first try, but if he doesn't, he'll have to go back as many times as necessary to ensure he has provided adequate margins. CPT guidelines state: "To report a reexcision procedure performed to widen margins at a subsequent operative session ... see codes 11600-11646."

Diagnosis tip: If the ENT excises a malignant lesion and must re-excise the same lesion to ensure adequate margins, you should use the same diagnosis for the reexcision as you did for the initial excision, even if the pathology report for the re-excision returns negative for malignancy, according to AMA recommendations. In this case, your diagnosis is 195.0 (Malignant neoplasm of head, face, and neck).

Watch out: All procedures include a minimal E/M, so unless the ENT can provide documentation for a significant, separately identifiable E/M service above and beyond that usually included in the excision, you are limited to reporting the excision only.

Scenario 2: The FP refers the patient to the ENT for a skin lesion removal from the forehead. This time, however, the ENT views the lesion as potentially more serious and not diagnosable by simple exam. The ENT performs a thorough exam and biopsy to determine the nature of the lesion. The biopsy returns positive for malignancy, and the ENT schedules the patient for excision at a later date in the operating room (OR).

Solution: First, you should report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), says Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist for UC Health Ear, Nose and Throat in Cincinnati, Ohio. Your diagnosis for this stage is 709.9 (Unspecified disorder of skin and subcutaneous tissue).

In this case, if the ENT documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...), Nesary says.

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to distinguish the E/M service as significantly above that included with the biopsy, Hardison says.

On the later date of the excision, you will report the excision (for instance, 11644, ... excised diameter 3.1 to 4.0 cm), as well as any allowable wound repair (such as 12052, Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm). Had the closure involved only a simple closure, you would not have reported the closure, as payers consider simple closures inclusive to lesion excisions.

Scenario 3: The ENT suspects squamous cell carcinoma on the cheek and excises the lesion in the office. The pathology report returns later showing positive margins -- meaning that the ENT did not remove all the malignancy and must excise additional tissue. The ENT schedules an additional excision for wider margins in the OR and takes a frozen section. This time the pathology report returns negative.

Solution: Report the initial excision (for example, 11642), as well as any allowable wound repair and E/M services (if appropriate) that the ENT provides in his office. For the additional excision on a later day in the OR, report another excision code as appropriate to the size of the tissue removed (for example, 11643, ... excised diameter 2.1 to 3.0 cm), as well as any allowable wound repair.

If the re-excision took place during the initial procedure's (11642) global period (within 10 days of the initial procedure), you must append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the lesion excision code, Nesary says.

The ENT will want to excise all malignant tissue on the first try, but if he doesn't, he'll have to go back as many times as necessary to ensure he has provided adequate margins. CPT guidelines state: "To report a reexcision procedure performed to widen margins at a subsequent operative session ... see codes 11600-11646."

Diagnosis tip: If the ENT excises a malignant lesion and must re-excise the same lesion to ensure adequate margins, you should use the same diagnosis for the reexcision as you did for the initial excision, even if the pathology report for the re-excision returns negative for malignancy, according to AMA recommendations. In this case, your diagnosis is 195.0 (Malignant neoplasm of head, face, and neck).