Podiatry Coding & Billing Alert

Look for details on nail bed services, test results to increase your coding accuracy.

If you automatically assign 11100 when your physician specifies a patient’s biopsy site, you’re wrong. Well, in certain cases. Using CPT®’s site-specific codes can dramatically increase your coding accuracy. Plus, they pay more.

Bottom line: Don’t miss out on additional money for the additional work. Site-specific biopsy codes tell the payer that the physician performed a biopsy at a specific location, rather than a generic integumentary based biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). A site-specific biopsy code also represents a more complicated procedure than 11100 does, and merits the increased rate.

Make Use of a Variety of Options

Diagnosing skin lesions can be difficult as you may often see an unclear clinical picture. In these cases, a biopsy is required. You can bill a biopsy of skin and subcutaneous tissues by using the CPT® code series 11100 for a single lesion and then add 11101 (…each separate/additional lesion [List separately in addition to code for primary procedure]) for each additional lesion. Closure of the biopsy is included in the procedure fee allowance.

If you perform a shave biopsy in which you essentially remove the entire lesion, choose from the 11305-11308 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia…) code series.

For a biopsy of the toenail/nail unit, you would report CPT^® code 11755 (Biopsy of nail unit [e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds] [separate procedure]).

Know Your Nail Bed Coding Rules

As an example, say a patient with a pigmented lesion of the nail bed presents to your practice. Your podiatrist suspects trauma but feels he should perform a nail bed biopsy to rule out melanoma and documents his service. Your first thought in coding this scenario might be to bill 11100. But you should instead bill 11755.

CPT^® 11755 is more accurate and also pays more than code 11100. (11755 has 3.77 total non-facility (office) RVUs; 11100 has 2.93 non-facility (office) RVUs.) A nail bed biopsy requires cutting through the plate, getting a biopsy of the nail bed, and likely suturing the wound. This process is much more complicated than a typical skin biopsy, and demands more pay.

You can use the “punch biopsy” code 27613 (Biopsy, soft tissue of leg or ankle area; superficial) in certain cases. It’s up to you to determine, all things being equal, which code is to your advantage to bill. Code 11100, while having a “0” day Medicare global period, is valued at 2-3 times less than 27613, which has been assigned a 10-day Medicare global period.

If you normally see your post-punch biopsy patients for follow-up within ten days of the procedure, it may be worth your while to bill 11100, and charge for the post-surgical E/M. If the patient will not be seen for 11 to 14 days post-biopsy, then 27613 should better fit your needs.

Take Care When Taking Nail Portions

There is some controversy as to the proper use of this code for a biopsy of the nail itself. You would not use this code when simply clipping a loose or crumbling portion of nail for KOH or DTM testing of the nail.

Keep in mind that there may be specific instances when a more definitive diagnosis is necessary and one needs a PAS stain. In these cases, the physician will remove a larger and more proximal piece of nail. Clearly document why such a definitive test is required as opposed to other types of fungal nail testing.

Check with the specific insurance company regarding what it requires for documentation of onychomycosis or tinea. Routinely performing nail biopsies as a means of obtaining a fungal specimen is of questionable medical necessity and may result in audits.

Report Multiple Biopsies for Separate Sites

When your physician performs multiple biopsies, you need a tool to unlock the claim’s payment. Clarify the circumstances to the payer using modifiers. For example, your physician performs a biopsy of a lesion on a patient’s nail bed. He performs another biopsy on the top of the patient’s foot, suspecting melanoma due to excessive flip-flop wear without sunscreen.

What to report: Because your physician specifies the site in the detailed documentation, you can see that the documentation justifies reporting 11755 for the biopsy on the patient’s nail bed and 11100 for the second biopsy.

Wait for Path Report Before Applying Dx

You should always wait until the pathology report comes back to choose the proper codes to report, even though this will not always affect the CPT® code you will wind up choosing. Instead, waiting for the path report reflects good business practice — and correct coding from a diagnosis coding standpoint.