Podiatry Coding & Billing Alert

Hint: Pay extra attention to size and location for coding accuracy.

If your payer consistently denies claims you submit for foot lesion excisions, perhaps you should be looking more closely at the details of the size, location, or the depth of the lesion from the physician documentation. Many coders erroneously report lesion debridement or excision as foot tumor procedures. Here’s your dilemma — do you wait for the pathologist to measure the excised lesion and increase costs or proceed without the pathology report and end up with a misdiagnosis? Use these tips to ensure correct diagnosis — and ethically maximum payout.

Tip 1: Line up Lesion Size and Type

If you have asked for a pathology report, review the documentation for excision size and location as lesion excision sizes ranges from small to large lesions. To determine the correct code for either a lesion or tumor procedure, it is important that your podiatrist’s operative report indicates the size, depth, and location of each growth. Accurately determining lesion or tumor size will also ensure that your podiatrist gets properly compensated for the depth and difficulty of the service he provided. “The podiatrist may perform a shaving or excision based on the depth of the lesion,” says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. For a single lesion that your podiatrist documents, you should report codes from the following, depending on the size:

Shaving: If the podiatrist shaves off a single epidermal or dermal lesion, then you can choose from:

• 11305 — Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
• 11306 — … lesion diameter 0.6 to 1.0 cm
• 11307 — … lesion diameter 1.1 to 2.0 cm
• 11308 — … lesion diameter over 2.0 cm.

Excision: Based on the finding that the lesion is benign or malignant, the provider may excise the lesion, excluding a skin tag, including margins. You can choose your excision codes from:

• 11420-11426 -- Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ... -- excised diameters ranging from 0.5 cm or less to over 4.0 cm
• 11620-11626 -- Excision, malignant lesions including margins, scalp, neck, hands, feet and genitalia ... -- excised diameters ranging from 0.5 cm or less to over 4.0 cm.

Important: To differentiate between codes for shaving and excision, look at the removal’s depth. Technically, any time a provider removes skin tissue, it is an excision. For coding purposes, however, excision is narrowly defined as involving full thickness, or through the dermis, removal of a lesion. Shaving, in contrast, involves sharp removal without a full thickness dermal excision.

Tip 2: Make Sure of the Measurements First

You should select the appropriate lesion excision code based on the size mentioned in the physician’s report. If the physician doesn’t measure the lesion before he cuts it out, you can effectively say goodbye to half of your possible reimbursement.

According to experts, once the specimen is in the jar, the specimen shrinks down to half its original size. If the physician doesn’t put the original size in the note, the coder has to code based on the smaller excision size listed in the pathology report, which will cost the practice a lot of money.

CPT^®’s excision sizes, including margins, are based on the physician’s measurements. The practice should keep reminding and training providers to measure an excision and document it with a statement, such as, ‘I’m going to excise this X cm length by X width lesion. I took 4 cm margins.’ Explain to your physician the financial impact of including these details.

Add it up: “You should determine the lesion size for coding purposes based on the largest lesion diameter plus two times the narrowest margin,” Beresh informs. Remember, margins are on all sides of the lesion, so you’ll double the smallest margin measurement. For instance, taking a 4 cm margin on all sides of the lesion equals a total of 8 reportable cm in addition to the diameter of the lesion itself. “Don’t let your physicians cut themselves short.

For example, if your physician has noted that “excised foot lesion 1.0 cm length by 2.0 cm width lesion, taking 0.2 cm margins,” and the pathology report comes back benign, you can 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) for the 2.4 cm codeable size ([2.0 lesion diameter] + [0.2 x 2 margins]). If, however, the podiatrist had failed to document the size and the pathology report measured a 1.0 cm lesion plus 0.1 margins, you could code only 11422 (... excised diameter 1.1 to 2.0 cm), resulting in a loss of $27 (Code 11443 pays $205.54, while 11442 pays $178.23 for non-facility national amount using 35.9335 conversion factor).

Forgetting to give the podiatrist credit for the margins would reduce the code to 11421 (... excised diameter 0.6 to 1.0 cm). This would cost the practice approximately $46 (Code 11421 pays $159.54 for non-facility national amount using 35.9335 conversion factor).

Take note: Lesion size determines the proper CPT^® code to use and, therefore, the proper payment. You also have to remember that in determining the lesion size, your podiatrist must add the size of the surrounding margins that were removed.

Tip 3: Don’t Rush For Diagnosis Codes Before Path Report

You should always choose the malignant or benign excision code based on the results of the pathology report, even if the physician does not have that information at the time of surgery. The pathology report offers the definitive diagnosis that serves as the basis for the CPT^® excision code selection.

Your podiatrist may have identified the lesion as benign or malignant based on his visual evidence, but you should still wait for the pathology report to code the excision. This will help you circumvent any malpractice findings for the physician if a benign-appearing lesion really ends up being malignant. On the flip side, you don’t want to mislabel the patient. The diagnosis could cause the patient’s payer to drop coverage.

Follow this: Always choose the excision code after the pathology report returns. If the pathology shows malignancy, we code the procedure as excision of a malignant lesion. Downplay concerns that patience could cause payment losses. Sitting and waiting for three to four days for the path report does not change cash flow, assure experts.