Otolaryngology Coding Alert

Question: The otolaryngologist excises a lesion from the patient’s nose with an excised diameter of 2.0 cm. They intend to do an adjacent tissue transfer (ATT) for minimal scarring but wait for the pathology report to determine if the lesion is malignant and to ensure clear margins. With a pathologic diagnosis of basal cell carcinoma (BCC), margins clear, the ENT performs the ATT four days later. How should this be coded?

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Answer: You should code the initial procedure using 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm) and associate it with C44.311 (Basal cell carcinoma of skin of nose) for the initial diagnosis of BCC. Keep in mind, the excision has a 10-day global period.

Tip: Remind your ENTs to measure and document the excised diameter of the lesion accurately. In this case, had the excised diameter been 0.1 cm larger, the coding would have been 11643 (… excised diameter 2.1 to 3.0 cm). Sometimes, the surgeon indicates round measurements instead of specifying the actual, precise measurements. This can cause the case to be under- or overcoded, which may put them at risk of improper payments and create compliance problems.

The correct code for the tissue transfer performed four days later is 14060 (Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less). Assign Z42.8 (Encounter for other plastic and reconstructive surgery following medical procedure or healed injury) as the principal diagnosis and Z85.828 (Personal history of other malignant neoplasm of skin) as a secondary diagnosis on the claim for the ATT.

Note: Had the closure via ATT taken place on the same day as the lesion removal, you could only code the closure because adjacent tissue transfer/rearrangement codes include lesion excision. This is because CPT^® considers the lesion excision preparation for the ATT or rearrangement.

Mind the global: Because the tissue transfer happened during the excision’s 10-day global period, reporting 11642 and then 14060 four days later would result in a denial. However, you can overcome bundling issues by reporting the second surgery with modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period), as the ATT was a planned staged procedure — the ENT waited for pathology results before closing the defect.

Tip: Notice that modifier 58 does not require a return to the operating room.

Cost impact: When you use -58, the global period restarts, so your surgeon should get 100 percent of the fee schedule payment for the service submitted with modifier 58.