Pediatric Coding Alert

And make sure you know your payer's rules for reimbursement.

Common in newborns, milia can affect people of all ages. These small epidermoid cysts usually appear as bumps around the cheeks and eyelids and will generally go away without treatment after a month or two.

Sometimes, however, milia will require treatment. For some, this could mean having the cysts removed using a minor surgical procedure.

So, do you know what to do when your provider treats a patient with milia in your practice? Read on, and make sure you avoid these four common myths about treating this condition.

Myth 1: Destruction and Removal are the Same Procedure

The way you document the treatment will obviously be the same way that your pediatrician documents the procedure in his or her notes. Just make sure you don't leap to use 10040 (Acne surgery (eg, marsupialization, opening or removalof multiple milia, comedones, cysts, pustules) simply because the code mentions milia in its descriptor. The 10040 code is a removal code that involvesincision and drainage of the lesions using an extractor, a fine-tipped needle, or ablade.

That is very different from the procedure described by 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). According to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, this code describes the standard procedure used to treat milia.

"Milia are typically removed with a chemical peel," Holle advises coders, and if your provider uses chemical agents like trichloroacetic acid, hydroxy acid, or salicylic acid to treat the lesions, the destruction code 17110 is the most appropriate one to use.

Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington, agrees with Holle. "If these are true milia," Bucknam believes, "they would not be considered acne, so 17110 would be the appropriate code for any kind of destruction of this type of benign lesion."

Myth 2: You Can Code 17110 and 17111 Together

If your provider decides that destruction is the best procedure to remove the milia, then you will also have to document how many lesions your pediatrician destroyed. Both 17110 and the subsequent code 17111 (... 15 or more lesions)  specify the number of lesions, but coders should not make the mistake of viewing 17111 as an add-on code for 17110 and using both codes together. Simply put, if your pediatrician removes 14 lesions or less, you report 17110; anything more and 17111 is the only code you would use.

Myth 3: You Would Use L72.8 to Document Milia

The confusion here lies in the fact that there is no specific ICD-10 code for milia. That might lead a coder to reach for L72.8 (Other follicular cysts of the skin and subcutaneous tissue). However, this code is not correct.

As milia are, in fact, "very small, superficial epidermoid cysts" (Source: https://emedicine.medscape.com/article/1061582-overview), the correct code to link with the appropriate procedure code is L72.0 (Epidermal cyst).

Myth 4: Your Payer Will Reimburse for the Procedure

Actually, Medicare and payers that follow its guidelines regard removal of such benign lesions as milia, skin tags, moles, and viral warts as cosmetic surgery, which is not regarded as a reasonable or necessary service per Chapter 16 of the Medicare Benefit Policy Manual (Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf).

However, Medicare does make an exception to this rule, which many payers will follow, on the grounds of medical necessity (See, for example, Local Coverage Article A54602: Removal ofBenignSkin Lesions, found at https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54602&ver=3).

Consequently, as both Holle and Bucknam advise, your documentation should prove medical necessity for the procedure. One way to do this, Holle suggests, is by showing that the milia are "in an area that is being rubbed or is getting infected in some way."

Bucknam agrees, adding that "if the lesions are in a place that is limiting function, such as an eyelid, the corner of the mouth, or the nostrils, this would be considered medical necessity." In such cases, Bucknam recommends that "pictures can be very helpful if proof is required by the insurer."

But whichever way you decide to document the medical necessity of the destruction, it is vitally important that you coordinate with your payer to determine who will foot the bill prior to your pediatrician performing the procedure.