Otolaryngology Coding Alert

Question: A family practitioner sent a patient to my ENT to remove a skin lesion. The ENT thought the lesion might be serious, so she performed a thorough exam and biopsy. The biopsy came back positive for malignancy, and the ENT scheduled the patient for excision at a later date in the operating room. Can I bill a separate E/M service, or just the biopsy?

New York Subscriber

Answer: 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 ...). 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.

The rest of the coding: Don't forget to report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

Read the notes: The documentation should reflect a significant, separately identifiable E/M service; you-re looking for a history, exam, and medical decision making (MDM) separate from a procedure note for the biopsy. The decision for the biopsy will probably be found in the MDM of the E/M part of the op note.

Second visit: For the patient's next OR visit, you-d report the excision (for instance, 11644, - excised diameter 3.1 to 4.0 cm), and any allowable wound repair (such as 12052, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm). If the ENT performed a simple repair, you-d only code the excision.