Part B Insider (Multispecialty) Coding Alert

Published on Wed Jul 26, 2006 PDF

CCI restores troublesome general surgery edits

If you-re billing for lesion excisions (11400-11646) on the same date as adjacent tissue transfers (14000-14350), make sure the procedures happen in distinct anatomical areas or in a different session--or else.

Background: The Correct Coding Initiative version 12.1 deleted a sticky set of edits. As of April, lesion excision codes 11600-11646 were no longer components of tissue transfer or rearrangement codes 14000-14300. (See PBI, Vol. 7, No. 11.)

The update: The latest version (12.2) of CCI, however, again lists lesion excisions 11400-11646 as bundled to (included in) all tissue transfer codes in the range 14000-14350.

In addition, introductory text in Chapter 3 (Surgery: Integumentary System) of the NCCI states, -Excision CPT codes (11400-11646) - are not to be separately reported when CPT codes 14000-14350 are reported.- These instructions mimic similar (although less clearly stated) guidelines set forth in the CPT Manual.

Bad news: Continued bundling of 11400-11646 to 14000-14350 is not good for general surgeons and plastic surgeons who work  together, with the surgeon performing the lesion excision and the plastic surgeon the adjacent tissue transfer. -We often have a general surgeon doing the lesion removal and a plastics guy doing the repair,- explains Terri Brame, operations manager for the Division of Clinical Revenue at the University of Washington Department of Surgery.

The problem: The physician fee schedule database says you may not report co-surgeons using modifier 62 (Two surgeons) for adjacent tissue transfers 14000-14350, Brame explains. So if a general surgeon removes a lesion and a plastic surgeon performs the adjacent tissue transfer later in the same session, you cannot list the surgeons as co-surgeons. Because the lesion excision is bundled to the tissue transfer, the general surgeon has no way to gain payment for his portion of the service.

Possible solution: In such a case, the only real solution is for one physician to report the adjacent tissue transfer and, through a separate billing agreement, reimburse the second surgeon for his portion of the service. But such an arrangement may be tricky to organize at best.

When To Turn To Separate Billing

The CCI includes a modifier indicator of -1- for the edits bundling 11400-11646 to 14000-14350, which means that you may use modifier 59 (Distinct procedural service) to override the edits in cases when the lesion excision and adjacent tissue transfer occur at different locations, or during separate, distinct operative sessions.

Example: The surgeon performs a single lesion excision on the right forearm, followed by adjacent tissue transfer at another location near the elbow. Report the lesion excision followed by adjacent tissue transfer using the appropriate tissue transfer code only (for example, 14021, Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm). You may report the lesion excision only in a separate location using the appropriate lesion excision code (for example, 11401, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.6 to 1.0 cm), with modifier 59 appended.