Pediatric Coding Alert

Also: see when and how to append modifier 59.

Removal of small, benign lesions, such as warts and skin tags, are usually no big deal for the physician, but sometimes coding them can be a pain. Deciphering which codes to use for which lesions can be tricky.

Here, we’ll walk you through how to correctly code warts, skin tags, and their associated removal procedures.

Identify Common Diagnosis Codes

Warts are small, fleshy bumps on the skin or the mucous membrane caused by the human papillomavirus (HPV). They can pop up just about anywhere on the body, but they’re most commonly found in the genital area, feet, and hands. While they can go away on their own, they sometimes require treatment. The four most common ICD-10 codes associated with warts:

• A63.0 (Anogenital (venereal) warts)
• B07.0 (Plantar wart)
• B07.8 (Other viral warts)
• B07.9 (Viral wart, unspecified)

Understand the Wart Removal Codes

Generally, warts need to be completely excised, which requires the physician cutting into the skin to completely remove the lesion, then closing the wound with stitches. Or as CPT^® puts it, “Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.” Destruction typically involves ablating (i.e., removing) the lesion through other means such as electrosurgery or cryosurgery. These methods are typically used for larger or deeper lesions. Lesion removal by excision is coded differently than removal by destruction, and both are coded differently than paring.

For wart destruction, you’ll usually reach for 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) or 17111 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions).

Caution: Sometimes, a patient will come in for wart destruction but the warts themselves present with a raised, calloused area that the practitioner will shave down prior to the administration of the destruction agent. However, paring 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) with 17110 for the same treatment location is not appropriate. “This is considered as double-dipping. The paring of the lesion is considered to be part of the overall treatment for the removal of the wart with liquid nitrogen, so therefore, we would only be able to bill CPT^® 17110 and not in addition to 11055 for the same treatment area,” says Erin Hall, CPC, CPCD, coding lead at MediRevv, a Tegria Company in Coweta, Oklahoma.

Modifier alert: Not coincidentally, NCCI edits bundle the two codes unless the edit is appropriately overridden with a modifier, such as modifier 59 (Distinct procedural service) to indicate separate lesions removed from separate anatomic areas using different techniques.

Review Skin Tag Diagnosis Coding Requirements

Skin tags, sometimes referred to medically as acrochordons, are small, soft, skin-colored growths that hang off the skin. They’re common, harmless, but many patients find them unsightly. They can often occur on or near skin folds, such as the neck, under the arms, around the groin, or under the breasts. For this type of lesion, turn to L91.8 (Other hypertrophic disorders of the skin).

Medical necessity alert: For this type of lesion, the payer may require you report a secondary ICD-10 code to support the medical necessity of removal. For instance, you’ll find this rule in Noridian Healthcare Solution’s local coverage article “Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)” (www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57161.) Other payers may similarly require an additional diagnosis to cover skin tag removal. Therefore, a common error is reporting L91.8 alone. Payer policies may specify which codes support medical necessity, but some possible secondary ICD-10 codes are:

• R20.0 (Anesthesia of skin)
• R20.1 (Hypoesthesia of skin)
• R20.2 (Paresthesia of skin)
• R20.3 (Hyperesthesia)
• R20.8 (Other disturbances of skin sensation)

Rely on 11200 and +11201 for Skin Tag Removal

Report skin tag removal with one or both of the following CPT^® codes:

• 11200 (Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions)
• +11201 (Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure).

Though not mentioned in the descriptors, these codes include most traditional removal methods, including removal by scalpel, ligature strangulation, or chemical/electrical cautery, as described by the CPT^® guidelines for the codes. The thing to pay attention to here is how many lesions the practitioner removed during the visit. “Report 11200 for the first 15, and +11201 for each additional 1-10 skin tags. Reporting +11201 requires that the physician remove a minimum of 16 lesions in total. You cannot report +11201 without also using 11200 on the same claim,” explains Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Note: “Reporting removal of more than 25 skin tags in one session is considered medically unlikely, and a clinical NCCI [National Correct Coding Initiative] medically unlikely edit (MUE) of 1 has been established for code +11201,” says Pohlig. “The MUE Adjudication Indicator (MAI) for +11201 is 3 however, so it is possible for Medicare administrative contractors to pay units of service in excess of the MUE value if the denial is appealed and there is adequate documentation of medical necessity of correctly reported units,” Hall adds. You can find this information in Chapter I.V of Medicare’s National Correct Coding Initiative Policy Manual.

Modifier alert: When the patient has multiple skin tags on their neck in addition to a couple of stubborn warts on their foot, you should append modifier 59. Many coders append modifier 59 to whichever codes have the lower relative value units (RVUs). Code “17110 has 3.37 total RVUs in the nonfacility setting, 17000 has 1.99 total RVUs, and +17003 has a total RVU of 0.20. This will therefore be coded as 17110 x 1 unit, 17000 x 1 unit + modifier 59, and 17003 x 1 unit + modifier 59,” says Hall.

Note: “Errors commonly occur without knowing all of the procedural details,” Pohlig says. If the provider’s notes aren’t clear, the coders have the opportunity to educate providers on how documentation affects coding.