Primary Care Coding Alert

If you wait until after pathology, lesion (and payment) will be smaller

When your FP performs lesion excisions, you-ll need to know the lesion type, the body area, and the exact measurement of the excised area.

Without these pieces of information, you risk miscoding the encounter -- or missing out on reimbursement that your office is entitled to. Follow this expert advice to choose the proper lesion excision code for each encounter.

Determine Lesion Type First

On your lesion excision claims, you should know whether the physician removed a benign or malignant lesion from the patient, says Cindy Earl, coder at IMA Inc. in Bloomington, Ind. When reporting lesion repair, choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions, she says.

Benign or malignant? There is no way for the coder to know whether the lesion was benign or malignant on her own, but she cannot choose the appropriate excision code without a benign or malignant diagnosis. The smartest move in this situation is to wait for the pathology report to confirm a diagnosis, Earl says. That way, you-ll know for sure whether the lesion was benign or malignant before you file the claim.

For Coding, CPT Designates 3 Body Areas

Once you confirm whether the lesion is benign or malignant, you should narrow your code choice further based on which body area the physician operated on. For coding purposes, CPT breaks lesion removal codes into three body areas:

• trunk, arms, legs (11400-11406, 11600-11606)
• scalp, neck, hands, feet, genitalia (11420-11426, 11620-11626)
• face, ears, eyelids, nose, lips, mucous membrane (11440-11446, 11640-11646).

Exception: If the physician is treating a patient for hidradenitis, you will not choose from the above codes. On hidradenitis repairs, you would choose the appropriate code from the 11450-11471 set, regardless of lesion body area.

Include Margins on Lesion Measurements

Once you have discovered the lesion type and location, you-re ready to record the lesion's exact measurement. When calculating lesion size, don't just measure the lesion -- be sure to report the total excised diameter on the claim, Earl says. To determine the appropriate lesion excision size, measure the lesion's widest diameter point, then add double the width of the narrowest margin.

In other words: Widest diameter point + narrowest margin + narrowest margin = total excision size.

Consider this example: The physician treats a lesion on a patient's left arm. The operative report indicates that the lesion was benign, its diameter was 1.4 cm at the widest point, and the physician also excised a skin margin of 0.2 cm.

You would add the lesion diameter (1.4) and the margin on both sides (0.2 + 0.2), and your total excision area would be 1.8 cm. On the claim, you should report 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter 1.1 to 2.0 cm) for this encounter.

Best bet: Since lesions will shrink when the pathologist analyzes them, the physician should measure and document the excision area before excising the lesion.

Excisions From Same Area Offer 2 Coding Choices

There are instances in which the FP removes multiple lesions from the same body area. If the FP removes multiple lesions via multiple excisions, you-ll report multiple excision codes, says Sheldrian Leflore, CPC, revenue management educator with The Coding Group in Carlsbad, Calif. For example, the FP removes a 1.0-cm benign scalp lesion with a 0.5-cm margin. During the same session, he also excises a 0.5-cm benign neck lesion with a 0.2-cm margin.

Since the FP performed two incisions on the patient (one on the scalp, one on the neck), you-d report a CPT code for each excision:

• report 11422 (... excised diameter 1.1 to 2.0 cm) for the excision of the scalp lesion.
• report 11421 (... excised diameter 0.6 to 1.0 cm) for the neck lesion excision.
• append modifier 59 (Distinct procedural service) to show that the excisions were separate procedures, because they occurred in different body areas that use the same CPT code family.

If Body Areas Differ, Leave Modifiers Off Claim

When the excisions occur in different body areas that do not use the same CPT code family, things are less complicated for the coder. You-ll report two codes in these scenarios, and modifiers are typically unnecessary, Leflore says.

Suppose the FP removes a 1.0-cm malignant lesion from a patient's lip with a 0.3-cm margin, then excises a 0.5-cm malignant lesion from a patient's neck with a 0.2-cm margin. On the claim,

• report 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm) for the lip lesion excision.
• report 11621 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm) for the neck lesion excision.

-It would not be inappropriate to assign modifier 51 (Multiple procedures) in this scenario because multiple surgical procedures are being performed,- Leflore says. However, most insurers will accept these claims without any modifiers. If you-re unsure of your payer's policy on coding for multiple lesion excisions, contact it before deciding how to file the claim.

Report Intermediate or Complex Closure Separately from Excision

Simple closure of the excision site is bundled into all of the lesion excision codes, Earl says. However, intermediate and complex closure of excision sites may be reported separately.

When the FP performs an intermediate closure, you-ll choose a code from the 12031-12057 series, Leflore says. For complex closures, you-ll choose from the 13100-13153 series.

Example: The FP excises a 3.2-cm benign lesion with 0.3-cm margins from a patient's scalp. During the session, she also performs a 2.9-cm layer closure of the wound site. On the claim,

• report 12032 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) for the closure.
• report 11424 (... excised diameter 3.1 to 4.0 cm) for the excision.
• append modifier 51 (Multiple procedures) to 11424 to show that the site closure and the excision involved multiple procedures.

Remember: When reporting modifier 51 on claims, always append the modifier to the lowest-valued code. In most cases, intermediate and complex wound closure codes have a higher value than lesion excision codes.