Otolaryngology Coding Alert

Set yourself up for success by adopting these Medicare guidelines.

Occasionally, otolaryngologists will be called upon for the removal of different ailments of the integumentary system. Needless to say, you should be fully prepared to handle any physician encounters for removal of lesions of the skin and subcutaneous tissue of the face or neck.

While the surgical act of removal and repair of a lesion of the face or neck may sound simple, there are enough National Correct Coding Initiative (NCCI) policies in place to leave you second-guessing even the most routine of procedures.

When it comes to lesion removal, incision, debridement, and repair codes, NCCI has an extensive list of rules and guidelines in place for almost any scenario you may find yourself in. Some of these rules might already be familiar to you, but other, lesser-known guidelines might change the way you think about lesion removal procedures going forward.

Consider these various NCCI policies to properly equip yourself for any lesion removal coding scenario.

Use 1 Code for Multiple Lesions of Same Site

The first rule to know on coding lesion removal is to only apply one CPT^® code for the removal of multiple lesions of the same continuous site. Medicare policy states, "If multiple lesions are included in a single removal procedure (e.g., single excision of skin containing three nevi), only one removal HCPCS/ CPT^® code may be reported for the procedure."

However, as long as the physician appropriately identifies lesions of separate anatomic locations, you may consider the use of multiple CPT^® codes with modifiers or 59 (Distinct Procedural Service) or XS (Separate Structure). In respect to these guidelines, Medicare states, "If multiple lesions are removed separately, it may be appropriate depending upon the code descriptors for the procedures to report multiple HCPCS^®/ CPT^® codes utilizing anatomic modifiers or modifier 59 to indicate different Revision Date (Medicare): 1/1/2017 III-7 sites or lesions. The medical record must document the appropriateness of reporting multiple HCPCS^®/ CPT^® codes with these modifiers."

Consider this rule: If a scenario arises where one lesion removal procedure begins using one method, but the surgeon converts to a different method to finish the procedure, apply the procedure code based on the final method applied.

Lesion Removal Includes Biopsy of Same Site

When coding lesion removals with subsequent biopsies, you should know Medicare's policy that a biopsy is included in a lesion removal code - as long as the surgeon performs the biopsy on the same site of the removal. Medicare's policy on this rule states, "The HCPCS^®/ CPT^® codes for lesion removal include the procurement of tissue from the same lesion by biopsyat the same patient encounter. CPT® codes 11100-11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane...) should not be reported separately. CPT^® codes 11100-11101 may be separately reportable withlesion removal HCPCS^®/ CPT^® codes if the biopsyis performed on a different lesion than the removal procedure."

In other words, you should only code the biopsy as separate from the lesion removal when the physician specifically documents that the biopsy site is completely separate from that of the lesion removal site.

"When deciding on whether to apply a biopsy code, make sure to analyze the procedure note to determine if the biopsy was, in fact, a segment of the same lesion," says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center's Department of Otolaryngology in Rochester, New York. "If the physician's intent is a partial biopsy, but total excision of the same lesion, then you should only bill for the excision code," Quinlan explains.

Know When to Code E/M Visits with Biopsy Evaluation

When the surgeon sees a patient for a follow-up evaluation and management (E/M) visit following a lesion removal and biopsy, you should be aware of how the pathology consultation fits into the E/M visit. Medicare's policy on pathology review in addition to an E/M visit are as follows:

"If a physician reviews pathology slides from previously removed lesion(s) in association with an evaluation and management (E&M) service to determine whether additional surgery is required, the review of the pathology slides is included in the E&M service. The physician should not report CPT^® codes 88321-88325 (surgical pathology consultation) in addition to the E&M code."

Therefore, based on these rules, your practice should not consider billing out for a pathology consultation if the initial basis behind the E/M service is a follow-up for the lesion removal. The pathology evaluation service is considered an included component of the E/M visit.