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 [...]