Primary Care Coding Alert

Hint: Be mindful of malignancy, method, and modifiers to make meticulous code choices.

Coding for skin lesions and their removals involves plenty of variables, and each variable requires new combinations of diagnosis and procedure coding to capture your provider’s services and the reasons for them.

So, to keep you on the top of your lesion removal coding game, we’ve put together three scenarios for you to ponder, along with some reliable analysis to help guide you through each possible coding permutation.

Scenario 1: After noting that a patient has a rough, scaly patch on his forehead, your practitioner diagnoses the patch as an actinic keratosis (AK) that is approximately 0.7 cm in diameter. As AKs can become cancerous over time, your provider decides to remove it using cryosurgery. What ICD-10 and CPT^® codes would you use to document the AK and its removal?

Answer 1: The correct diagnosis code for an AK would be L57.0 (Actinic keratosis). A note in ICD-10 also tells you to report an external cause code from W89.- (Exposure to man-made visible and ultraviolet light), if appropriate.

“Since the AK can become cancerous over time but is not classified as malignant at this point, I’d consider it premalignant,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “CPT^® directs users to 17000 [Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion] to report the procedure,” Moore continues, adding that “the size of the lesion is immaterial in this scenario.”

Coding alert: According to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, “since the AK is pre-cancerous, code 17281 [Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm] would not be appropriate, as this code is for malignant lesions only.”

Scenario 2: This time, your provider suspects the AK is more serious and orders a biopsy to determine whether it is malignant. The biopsy reveals that the AK has turned into a squamous cell carcinoma, so the practitioner decides to remove it. What ICD-10 and CPT^® codes would you use to document the removal this time, and can you separately report the biopsy?

Answer 2: “As we know the forehead is the specific location,” says Johnson, “the appropriate ICD-10 code this time would be C44.329 [Squamous cell carcinoma of skin of other parts of face] and not C44.320 [Squamous cell carcinoma of skin of unspecified parts of face].

As for the removal, you have options, according to Moore. “If removal means destruction, then you’re probably looking at 17281 [Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm],” Moore says.

“But if removal means excision,” Moore adds, “then you’re looking at 11641 [Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm], assuming the excised diameter including margins, and not just the diameter of the AK, does not exceed 1.0 cm.”

As for separately reporting the biopsy in this scenario, CPT^® guidelines preceding the skin biopsy codes state that obtaining tissue for pathology during an integumentary procedure, such as excision, destruction, or shave removals, is a routine component of such procedures and not separately reported. Per CPT^®, the use of a biopsy procedure code such as 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion) indicates that the procedure to obtain tissue for pathologic examination was performed independently or was unrelated or distinct from other procedures or services provided at that time.

In this scenario, the clinician performed the skin biopsy before the lesion removal. Most likely, the biopsy was done at a separate encounter and the specimen sent to a pathology lab to determine its malignancy. If so, the skin biopsy is separately reportable from the subsequent removal on a later date. Note that National Correct Coding Initiative (NCCI) edits otherwise bundle skin biopsy code 11100 into both 17281 and 11641 when reported for the same patient on the same date unless an appropriate modifier (e.g. modifier 59 [Distinct Procedural Service]) is appended to the skin biopsy code. This would be the case, for instance, if you biopsied a lesion on the right arm and excised a lesion on the left arm.

Scenario 3: The pathology report from the malignant AK removal comes back to your provider showing positive margins. As this means that the previous procedure did not entirely remove the malignancy, your provider determines that another removal is necessary and performs it nine days after the original removal of the carcinoma. Later, the pathology report comes back negative, showing the procedure has been successful. What codes do you report this time?

Answer 3: This time, Moore and Johnson agree, you’ll still report C44.329 for the malignant neoplasm, as the diagnosis has not changed. However, the procedure code will be slightly different.

Moore and Johnson note that you will still choose the appropriate excision or destruction code from 11640-11646 or 17280-17286, though in this scenario as before, your choice will also depend on the diameter of the new area to be removed. However, the excision or destruction that the provider performed in Scenario 2 carries with it a 10-day global period, which, as Moore explains, means you will have to follow CPT® instructions regarding appending modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) as “the procedure is performed during the postoperative period of the primary procedure.”

And, Johnson adds, “based on the fact that an updated lab report indicated positive margins, the use of modifier 76 [Repeat procedure or service by same physician or other qualified health care professional] would also be appropriate, as it shows additional information was received after the original procedure that warranted the return visit and procedure.”