Podiatry Coding & Billing Alert

You need to distinguish between subcutaneous vs. subfascial cuts.

If you’re not recouping what you’re owed for foot tumor excisions, you could be mistaking simple lesions for tumors or omitting debridement, lesion shaving, or excision codes. We’ll put you on the path to successful payouts by removing any confusion about the differences between tumors and lesions and their codes. 

Codes Change As You Go Deeper in the Skin

Before going into the actual coding scenarios, you should know two key terms that you will often encounter in your podiatrist’s op notes. Understanding the difference between these terms is pivotal to further coding success, as the excision codes have been stacked according to the difficulty faced by the physician in removing the lesion or tumor:

• Subcutaneous: The skin consists of two layers – the epidermis and the dermis. The epidermis is the top layer of skin and consists of four to five layers.The dermis is the thicker, fatty layer where the living parts of the skin are located. The subcutaneous level is located under the skin. 

• Subfascial: Located beneath the dermis of the skin is the fascia, which is a connective tissue layer that surrounds muscles, bones, and nerves, binding those structures together. Even the fascia has three layers. The excision becomes increasing complicated as you go down the fascial layers.

There are three common lesion treatment options: debridement, shaving, and excision. Keep a sharp eye out on the podiatrist’s notes to see how deep the podiatrist went to remove the lesion from the foot.

Debridement: This procedure involves the surgical removal of dead or damaged tissue or skin. Shaving is the removal of dead skin using a slicing or sawing motion. The CPT® manual provides the following debridement codes for lesions:

• 11000 (Debridement of extensive eczematous or infected skin, up to 10% of body surface) and +11001 (Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof [List separately in addition to code for primary procedure])

• 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) and +11045 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure])

• 11043 (Debridement, muscle and/or fascia [includes epidermis, dermis, and subcutaneous tissue, if performed]; first 20 sq cm or less) and +11046 (Debridement, muscle and/or fascia [includes epidermis, dermis, and subcutaneous tissue, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure])

• 11044 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; first 20 sq cm or less) and +11047 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]).
  

Excision: Excision is the surgical removal of an organ or tissue (lesion or tumor) through an incision as deep as or deeper than the full thickness of the skin. You require sutures to allow the surgical wound to heal for an excision.

Excision vs. radical resection: Other than excision, another procedure podiatrists use to remove tumors is radical resection (excision of all or part of an organ or tissue, along with the blood supply and lymph system supplying the organ or tissue). However, the distinguishing feature of resection is that it is used mostly to remove malignant tumors. You can spot radical resection in your procedure notes by looking at the large area covered by the procedure.

“Another distinguishing feature of excision versus radical resection is whether the podiatrist carried the procedure subcutaneously or subfascially. When the podiatrist removes tissues below fascia, then he is getting into radical resections,” informs Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Don’t Ignore the Size of Lesion

Check your podiatrist’s operative report, specially the size, depth, and location of each growth for correct choice of lesion excision code. The report will also provide a correct representation of the amount of work your podiatrist had to do, and hence his compensation. You can report from among the following CPT® podiatry codes for shaving or excision, depending on the size/diameter of the lesion removed:

• 11305-11308 —Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia... — lesion size from 0.5 cm or less to over 2.0 cm
• 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.

It is crucial to correctly document the total lesion size as it determines the proper code to use and the total size includes the surrounding margins that were removed.

Caution: Simple and intermediate repairs are now included in the codes for the excision, so don’t code a separate closure unless the physician documents that he or she performed a complex closure, adds Dr. Beresh.

Draw a Line Between Lesions and Tumors

You can decipher that the procedure is a tumor removal by checking the podiatrist’s documentation for terms such as “musculoskeletal in origin” or “soft tissue.” For reporting tumor removal codes, you will choose from among the CPT® 28000 series. However, before pinpointing the code, ensure to check the size of the excised tumor:

You can choose from among codes 28039 (Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater); 28041 (Excision, tumor, soft tissue of foot or toe, subfascial[e.g., intramuscular]; 1.5 cm or greater); 28043 (Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm); 28045 (Excision, tumor, soft tissue of foot or toe, subfascial[e.g., intramuscular]; less than 1.5 cm); 28046 (Radical resection of tumor [e.g., sarcoma], soft tissue of foot or toe; less than 3 cm)and28047 (Radical resection of tumor [e.g., sarcoma], soft tissue of foot or toe; 3 cm or greater).

Documentation Leads the Way in Soft Tissue Excisions 

Ensure that the physician has included the following information in the documentation when they excise a skin or soft tissue lesion:

• The nature of each lesion, whether benign, premalignant, malignant
• The size/diameter of the lesions (including the margins required for complete excision of each lesion)
• The location of the individual lesion excised
• The method of lesion removal/treatment (Excision, Shaving, Destruction, or any other method like chemosurgery)
• The depth of the excision of the individual lesions (Epidermal and/or dermal, subcutaneous, subfascial, deep fascial, wide resection, etc.) 
• Closure procedure after the excision (Simple repair, Layer closure, Complex repair, etc.)