Pediatric Coding Alert

Know the why, what, and where, and let your code choice measure up.

Skin conditions make up a large percentage of visits to your practice — as much as one-third of primary care encounters “involve at least one skin complaint” ” according to one source (Source: journals.healio.com/doi/10.3928/19382359-20211209-02). So, if your lesion removal coding isn’t on point, your revenue stream could take a big hit.

That’s why we reached out to a couple of our experts for their top shaving and excision tips, and here’s what they had to say.

Tip 1: Understand Purpose

When a pediatrician removes a section of skin from a patient’s body, he or she is attempting to diagnose a problem, to relieve a condition or, in some cases, both. If the purpose of the procedure is solely for diagnostic purposes, you can immediately reduce your options to the biopsy codes: 11102-+11107.

Once you know that the only purpose for the procedure is diagnostic, then narrowing down your biopsy code choice becomes a matter of determining location, technique, and number of lesions biopsied, as the following table illustrates:

Technique cause for coding confusion: As techniques are similar for both biopsies and removals, “focusing on the word ‘shave’ may lead you to report a shave removal when, in fact, the key word is ‘biopsy,’ which leads to this different set of codes,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

The removal codes have biopsies built in, so coding 11102-+11107 along with an excision or shaving code for the same lesion is not only redundant, it’s also reason for denial or audit. But it is also “possible and acceptable to biopsy a site on one part of the body, such as the right arm, and shave or excise another lesion on a different part of the body, such as the left arm,” says Moore. To code this, you should use an appropriate modifier, such as modifier 59 (Distinct Procedural Service) along with appropriate diagnosis codes, which may distinguish location and or laterality for the different lesions involved.

Tip 2: Understand Skin Depth/Technique

The anatomic structure of the integumentary system will determine the techniques your pediatrician will use to biopsy or remove lesions or warts from patients’ skin. If the lesion exists in the upper layers of the patient’s skin — the epidermis or dermis — your pediatrician will shave the lesion by placing a blade horizontal to the skin and moving it across the lesion, literally shaving it off without going down to the subcutaneous tissue.

If the lesion is deeper, your pediatrician will have to cut through the skin, going down into the subcutaneous layer to remove the whole lesion.

Don’t forget these codes to close the deal: Not only do these definitions help pinpoint the correct biopsy or lesion removal code, but they can also help identify the need for other codes. As shaving does not require a suture closure, no closure codes are generally reported. Neither do basic excisions, which include simple closures. But “intermediate and complex closures are separately reportable with 12031-12057 for intermediate closures or 13100-+13153 for complex closures,” Moore notes.

Tip 3: Understand Location

Both shaving and excision codes are grouped by location, as shown in the following table:

You’ll wait until the biopsy results come back before assigning the exact lesion excision code.

However, other site-specific biopsy or soft tissue excision codes may better describe a procedure than standard integumentary biopsy or excision codes, so double-check your pediatrician’s notes before assigning one of these codes.

Tip 4: Understand Size

Each of these shaving and excision codes are subdivided by size, with dimensions built into the code descriptors. But you’ll need provider documentation of the size of the lesion removed before assigning a definitive code to document exactly what your pediatrician performed.

For shaving procedures, size is simply the diameter of the area your pediatrician shaved. So, you’ll document a shave removal of a 0.4 cm diameter benign lesion on a patient’s arm with 11300 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less).

Remember margins, avoid error: For excision codes, however, your pediatrician will also need to document the margin around the area removed, which you will fold into the size calculation to determine code choice. So, if your pediatrician excises a benign lesion with a diameter of 2 cm from a patient’s hand and reports leaving a 0.2 cm margin around the lesion, you would add 0.4 cm (0.2 cm x 2) to the lesion diameter and report 11423 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm), as the total size of the excision diameter and the margin adds up to 2.4 cm.

The Final Word

“Integumentary lesion destruction is all about the numbers. It’s important to know how many were removed, what type of lesion, and how the lesions were destroyed,” Sydni Young, CPC-A, medical coder II for Healthcare Resource Solutions in Evansville, Indiana, concludes.