Primary Care Coding Alert

Faced with a host of new 2003 directives, family physician coders who already cite lesion excisions as one of their top problems will confront even greater challenges to ethically maximize reimbursement without double-billing. But you can x out billing errors by knowing the lesion's type, size, location, and how to bill for multiple excisions and closures. (For more advice, see "Lesion 101: Uncover Excision Basics" in article 2.)

When selecting a lesion excision code (11400-11646), you should first identify the lesion type. Family physicians often treat benign skin lesions, such as noncancerous growths, cicatricial (scar), fibrous, inflammatory, congenital (birth) and cystic lesions. In addition, they may treat malignant lesions, such as basal cell carcinoma, squamous cell carcinoma and melanoma.

CPT divides excisions into two subsections: benign (11400-11471) and malignant (11600-11646). "You should select the category based on whether the lesion is determined to be benign or malignant," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. But how can you choose a code when you don't know the lesion's pathology? "If the physician is confident that the lesion is benign, you can bill without the pathology report," she says. On the other hand, if the physician is concerned that the lesion might be malignant, you should wait for the report. That way, you don't label the patient with an incorrect diagnosis that could affect his ability to get future insurance coverage.

Once you have narrowed your choice to the correct pathology category, you should focus on the lesion's location. Both the benign and malignant subsections subdivide lesions into three body areas: 1. trunk, arms or legs (11400-11406, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs ...; 11600-11606, Excision, malignant lesion including margins, trunk, arms, or legs ); 2. scalp, neck, hands, feet, genitalia (11420-11426, benign; 11620-11626, malignant); and 3. face, ears, eyelids, nose, lips, mucous membrane (benign only) (11440-11446, benign; 11640-11646, malignant). For a visual breakdown of the codes, see the chart in article 2.

Now that you're in the right group of codes based on body site, the proper measurement will land you with the perfect score. Within each body area, you have six codes to select from depending on the excised diameter including margins. But you must first remember the measurement rules for 2003. Previously, you chose the code based on the lesion's diameter only, says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions, a physician reimbursement company in Lakewood, N.J. CPT 2003 expanded the measurement rules to include the narrowest margins required to excise the lesion. So the new codes refer to the lesion's excised diameter including margins. Once you have the excised diameter including the margins, you have your final code.

Your doctor should document the lesion size and the narrow margins before excision, Callaway emphasizes. "With the old method of coding, a nurse could document the size without any particular input from the physician," she says. The new method requires the family practitioner (FP) to document the lesion's size and estimate the expected margins prior to removal.

Although you have a lesion excision code, don't forget to bill for any additional lesions. Do not add lesions together. Instead, you should bill each lesion removal separately based on the lesion's size and margins, says Joy Newby, LPN, CPC, president of Joy Newby & Associates Inc., a reimbursement consulting company in Indianapolis.

For multiple lesions on the same body area, record the number of lesions excised in the units box. Some payers may prefer you to list each lesion individually and append modifier -59 (Distinct procedural service) to subsequent lesions from the same category, Newby says.

When the FP excises lesions from different body areas, append modifier -51 (Multiple procedures) to the lower-valued code. That way, the payer will reduce the less expensive procedure, rather than the higher-paying code, by 50 percent based on typical multiple-procedure rules.

After listing your lesion excision codes, identify which excisions required additional repair work. Most excisions require suturing to close the wound. But, because the excision codes include simple repair, you can separately report intermediate and complex repair only.

To determine whether you should report an additional code, look at the closure described in your FP's documentation. Family doctors often use one layer of sutures to close an excision, which constitutes simple closure, Callaway says. In this case, you should bill the excision code only.

On the other hand, the wound sometimes extends into the deeper layers of subcutaneous tissue in addition to the epidermis and dermis. If the excision requires more than one layer of sutures or if the physician determines the closure is complex for another reason, such as extensive cleaning or matter removal, you should bill an intermediate repair code (12031-12057, Layer closure of wounds ). When you report both the excision and repair codes, the rules for multiple surgical procedures apply, Newby says. So you should append modifier -51 to the lesser-valued procedure (the lesion excision).

For Medicare and carriers who follow National Correct Coding Initiative (NCCI) edits, do not bill a repair code for lesion excisions measuring 0.5 centimeters or less. NCCI 9.0 bundles the smallest excision code in each category (11400, 11420, 11440) with intermediate and complex repair codes (13100-13153, Repair, complex ). Lesions that small will usually not require more than simple repair, Cobuzzi says.

Unlike the lesion removal codes, which are reported per lesion, you should combine multiple repair codes of the same anatomic area. CPT defines three anatomic sites for intermediate repair: scalp, axillae, trunk and/or extremities; neck, hands, feet and/or external genitalia; and face, ears, eyelids, nose, lips and/or mucous membranes. Notice that the groups differ from the lesion excision body areas. You should add closures from each group together to bill one repair code per applicable section.