Otolaryngology Coding Alert

The lesion diameter now refers to the excised diameter:

Otolaryngologists will have to forget lesion size in their operative reports and list, instead, the excision size, as well as the narrow margins, Cobuzzi says. This is a huge shift from the way coders have instructed doctors to measure lesions, she points out. "Physicians and coders will require a major re-education."

The new wording reinforces how important it is for the physician to document the size before lesion removal, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "The doctor must now note that information and participate in determining the size by documenting the expected margin as well," she explains. "With the old method of coding, a nurse could document the size without any particular input from the physician." Coders should still rely on documented information, which should come directly from the physician's notes, she stresses.

The measuring change should benefit physicians monetarily, says Julie Robertson, CPC, an otolaryn-gology coding and reimbursement specialist for University ENT Specialists in Cincinnati. "The excision size is always bigger than the lesion size," she says. Therefore, the new measurement rules should allow doctors to bill more than before.

One problem, however, is that the measuring instructions and the lesion definition seem to contradict each other, Cobuzzi says. The introduction instructs the physician to measure the lesion, plus the margins, "prior to excision." The definition, however, is in the past tense, "excised." "How can the lesion be excised when the measurement is made before the excision?" she asks. CPT, perhaps, accepts this discrepancy because it bases the excised diameter on the physician's presurgery assessment.

Although CPT 2003 makes one significant change in lesion coding, it reinforces another long-held interpretation. CPT clarifies in the introductory language that you can code each lesion separately, Cobuzzi says, referring to the addition, "Report separately each lesion excised." "Coders previously followed this belief, but now the instruction is right in the CPT manual," she says. Payers who told coders to report the lesions' sum will have to contend with a definitive source that instructs otherwise.

For instance, an otolaryngologist removes two benign cysts one from a male patient's cheek and one from his lip. The physician measures the greatest clinical diameter of each apparent lesion, including the narrowest margins that she judges adequate for complete excision. The cheek lesion is 0.7 centimeters, and the margins are 0.2 centimeters on each side. The cyst on the lip is 0.2 cm, and the margins are 0.1 centimeter on each side.

For the cheek lesion, report 11442 ( excised diameter 1.1 to 2.0 cm) based on the location of the lesion (the face) and the excised diameter (lesion plus narrowest margins, 0.7 cm + 0.4 cm = 1.1 cm).

For the lip lesion, use 11440. The lesion is 0.2 centimeters, and the sum of the narrowest margins (0.1 cm + 0.1 cm = 0.2 cm) is 0.2 centimeters, so add these together to get the excised diameter 0.4 centimeters. For lesions on the same body area, append modifier -51 (Multiple procedures) to the lesser-valued procedure. Remember, multiple-procedures rules apply to modifier -51, so payers will reduce reimbursement for the second procedure by 50 percent. In summary, assign 11442 and 11440-51.

CPT 2003 also reinforces in the introduction's final paragraph that you should bill for intermediate/complex closure in addition to the excision:

The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 11400-14300, 15000-15261, 15570-15770. See page 54 for definition of intermediate or complex closure.

The language, however, does not say that you can also bill simple closure, Cobuzzi says. CPT breaks the instructions into specific codes that apply to benign lesion excision and reconstructive closure, she says. Therefore, the reconstructive closure type determines whether the reconstructive surgery includes the excision. For example, an adjacent tissue transfer (14000-14300) includes excision of the lesion as site preparation, so you would not bill the lesion excision. That's why CPT says to read the specific instructions attached to the reconstructive procedures to determine if lesion excision and reconstruction can be billed together.

CPT 2003 basically makes the same changes to the malignant lesion excision codes, Cobuzzi says. The introduction to Excision Malignant Lesions incorporates similar language alterations:

Excision (including simple closure) of malignant lesions of skin (e.g., basal cell carcinoma, squamous cell carcinoma, melanoma) includes local anesthesia. (See appropriate size and body area below.) For destruction of malignant lesions of skin, see destruction codes 17260-17286.

CPT reinforces in the following section to report each malignant lesion separately and to base the lesion size on the greatest clinical diameter plus the narrowest margins:

Excision is defined as full-thickness (through the dermis) removal of a lesion including margins, and includes simple (non-layered) closure when performed. Report separately each malignant lesion excised. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter).

Remember that the physician bases these measurements on his or her presurgery assessments, CPT states:

The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (e.g., with a skin graft).

The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of malignant lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11600-11646 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 14000-14300, 15000-15261, 15570-15770. See page 54 for definition of intermediate or complex closure.

Similarly, the definitions for 11600-11646 now include the narrow margins:

The lesion diameter now refers to the excised diameter:

The major difference between the changes to the introductions for benign and malignant lesions is that the malignant section adds a paragraph that discusses staged excision removal:

When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Append the modifier '-58' if the re-excision procedure is performed during the postoperative period of the primary excision procedure.

When a physician performs a re-excision at the same operative session because frozen section pathology shows that the original excision is inadequate, you should bill one code only, Cobuzzi says. "Select the code based on the final widest excised diameter," she says. Do not report the original excision in addition to the re-excision.

However, you may report a re-excision that occurs at a different operative session, she says. Use the appropriate malignant lesion excision code (11600-11646). If the physician performs the re-excision during the global surgical period of the primary excision, append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), CPT states.