Podiatry Coding & Billing Alert

Resist the temptation to overcode, and keep the lesion size plus margin equation simple

Your podiatry practice’s physicians might routinely perform lesion excisions, but the coding can be (almost) as delicate as the procedure itself. Lesion coding often involves multiple codes with different area multiplications that can lead to confusion.

Here, we address three types of procedures and the complications that each can add for a coder.

Don’t Overcode for Tissue Grafts

When you file a claim for adjacent tissue transfer (140xx), the work of the lesion excision is included in the graft.

Only code the defect, no matter how many “flaps” are needed. If the defect from the malignant lesion removal could not be closed as a straight closure and an adjacent tissue transfer was required for a good plastic closure, don’t code the removal of the malignant lesion separately.

Say the podiatrist completed an adjacent tissue transfer closure for a defect sized 3 cm by 2 cm. This means the defect size is 6 cm. The correct code based on the flap size will be 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less).

Even if the physician had to use two or three adjacent tissue transfers from different directions, only the 6 cm defect side would be coded and only 14040 would apply, not three times 14040 because adjacent tissue transfers are coded based on the defect.

For Skin Excisions, Bill Based on the Largest Final Margin Size

Each final lesion excision is separately coded and billed. If the physician completes multiple final lesion excisions of the same size in the same grouping that is covered by the same code, you should bill with either multiple units or by adding modifier 59 (Distinct procedural service) to each of the lesion codes after the first to indicate separate sites.

The correct billing method is based on how each payer will process the multiple lesion excisions. For example, simple closures are included in lesion excisions. If you’re reporting intermediate or complex closures, you add together those of the same type that have been performed in the same body area and grouped in the same code set. The total will determine the lesion length and lead you to the correct code.

Remember that all excisions and closures aren’t simple. Sometimes you can code for more extensive services.

However, if your physician completes an adjacent tissue transfer, flap, or graft, you do not bill both the excision and closure. You report the closure but not the lesion excision. Site preparation is included in adjacent tissue transfers, flaps, and grafts.

Watch for More Involved Closures

You can code intermediate layer closures as well as complex closures with lesion excisions, not just adjacent tissue transfers, flaps, or grafts. Many times, the closure has a higher RVU than the lesion excision. If you’re not paying attention to that, you’re missing a great opportunity.

For example, say one of your physicians removes a 0.5 cm lesion on the foot and sends it for frozen section and it comes back that the margins are still malignant. The physician than excises the margins, expanding the widest margins to 2.7 cm and sends it for frozen section. The margins come back malignant again and the widest margins are expanded to 3.1 cm. That sample was sent for frozen section and it came back as clear.

Although the physician performed three excisions, because it was a skin lesion, you report the lesion excision only as the largest margin excision, the 3.1 cm. Code 11624 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm) applies to the excision of this lesion. Since the lesion excision on the foot was so large, the physician performed a layered cosmetic closure.

Only simple closures are bundled with lesion excisions. As a result, the layered closure is separately coded and billed. The shape of the lesion excision requires a closure, which was 4.3 cm long according to the operative note. You should report the intermediate closure with 12042 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm). Code 11624 has 9.57 non-facility RVUs (office) and 12042 has 8.14 non-facility RVUs (office). Your final coding for the procedure should be:

• 11624
• 12042-51 (Multiple procedures).