Primary Care Coding Alert

Removal of lesions or growths is among the procedures family physicians perform most frequently in their offices. Common or not, however, this area of coding is considered a minefield by many coding experts because a variety of factors must be considered if the practice hopes to receive optimum reimbursement.

Three categories of codes are most often used when documenting lesion removal shaving, excision and destruction and each carries its own set of complications. Some coders may consider biopsies (11100-11101) as part of this category but, by definition, a biopsy is only a partial removal of tissue or fluid for diagnostic purposes, not complete elimination.

When to Use Shaving Codes

The simplest of the three methods of lesion removal is shaving, which is performed on superficial lesions like moles or other growths that do not appear to penetrate the fat layer, according to Emily Hill, PA-C, president of Hill & Associates, a coding and compliance firm in Wilmington, N.C. Coding for these procedures is included in the 11300-11313 series, depending on the location and size of the lesion (e.g., 11300*, shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5. cm or less or 11311, shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm).

These codes would be assigned if the physician is certain that removal will be very simple and that there is little chance of bleeding or any other sort of complication, she says. Use of local anesthesia is also included in the code.

Because of the nature of the procedure, there would be no need for a suture closure or reporting a repair code.

Hill cautions that shaving codes may mistakenly be reported for other simple procedures. Sometimes these are assigned when paring or cutting codes would be most appropriate (CPT 11055, paring or cutting of benign hyperkeratotic lesion [e.g,. corn or callus]; single lesion; 11056, two to four lesions; and 11057, more than four lesions). Coders need to remember that the paring codes are specifically for corns and calluses, and that the shaving codes would not be correct in these instances.

The same holds true for the removal of skin tags, she adds, which is reported with 11200* (removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions) and add-on codes CPT 11201 (each additional ten lesions [list separately in addition to code for primary procedure]).

Coding for Excision

Excision is the removal of a growth by cutting through the tissue and removing the entire lesion, Hill says. It may include local anesthesia, as well as simple suturing to close the wound. CPT codes assigned for excision include 11400-11471 for benign lesions and 11600-11646 for malignant lesions.

CPT allows family physicians to add modifier -22 (unusual procedural services) when removal is complicated or requires abnormal effort. In addition, 11450-11471 have been established specifically to report the excision of skin and subcutaneous tissue for hidradenitis, including codes for complex repairs.

Although many excisions can be completed with simple closures, there are circumstances when intermediate or layered closures are required, according to Lamon Willis, CPC, who specializes in physician billing and coding as a healthcare consultant for St. Anthony Consulting Group in Florida. When this occurs, coders usually will select a code from the intermediate repair series (12031-12057). They must be aware that the rules governing how these codes are reported differ from those describing excision.

Codes from this section are assigned according to anatomical region of the body and the sum of the length of repairs completed. When coding the excision itself, you would assign one code for each lesion, he explains. However, with the repair codes you would total the length of the repairs within the anatomical site which might include several lesions and report one code that represents that sum.

The repair codes would be reported in addition to the excision code, Willis says. When reporting both, family practice coders should add modifier -51 (multiple procedures) to the excision code. You would not want to add it to the repair code because it usually has the higher value. Modifier -51 results in a 50 percent reduction in payment, so you want to append it to the procedure code with the lowest value.

Example: A 43-year-old female has a 2.75-cm cyst on her back removed, and it requires a layered closure. The coder would assign 11403-51 for the excision, along with 12032 for the repair.

Destruction

Codes for lesion destruction include 17000-17250 (benign or premalignant lesions) and 17260-17286 (malignant lesions). Methods consist of electrosurgery, cryosurgery, laser and chemical treatments, and generally do not require closure. These codes include local anesthesia.

Although the destruction codes for malignant lesions are defined according to anatomical site and size like the shaving and excision codes, the destruction codes for benign or premalignant growths are assigned according to the number of lesions removed. Code 17000 is used to report the first benign lesion removed, Hill explains. Code 17003 is an add-on code for subsequent lesions. For instance, if the physician destroyed five growths using cryosurgery, the coder would report 17000 once and 17003 four times. There would be no need to append a modifier because 17003 is clearly defined as an add-on code.

Code 17004 would be assigned alone if 15 or more lesions were destroyed, she adds. Its not often that a family physician would find himself or herself in this situation, though. Similarly, 17106-17108 would seldom be reported because these codes represent procedures not often undertaken in a family practice setting. More commonly, 17110-17111 would be used when warts other than common or plantar warts are destroyed. (Common or plantar wart destruction is described in 17000-17004.)

Tips for More Effective Coding

Besides understanding which code applies to which situation, Hill points out several areas that coders must consider to ensure timely and accurate reimbursement.

1. Determine medical necessity. Medicare and many other carriers will not pay for lesion or growth removal unless the procedure is medically necessary, according to Willis. In general, medical necessity is proven only if the growth is symptomatic.

For instance, removal of a malignancy is clearly reimbursable as medically necessary, as would be the removal of a growth that bleeds frequently because it is irritated by clothing. A facial mole that has not changed shape, size or appearance, but is removed because it is unsightly, would not be considered payable by Medicare.

Experts advise coders to check with local carriers for their guidelines regarding medical necessity.

2. Measure lesion size. It is always advisable for the physician who removes the growth or lesion to measure it himself and record that measurement in the patient record, Hill says. Some practices may rely upon the pathologist to do this, but thats not ideal. For one thing, the pathologist may describe the specimen, not the entire lesion. In addition, shrinkage often occurs when the specimen is preserved.

If either of these situations occurs, she points out, a code for a lesion smaller than the one removed may be assigned which will result in lower reimbursement.

3. Wait for the pathology report. In both the excision and destruction sections of code, Hill says different codes would be assigned for a malignant or benign lesion. Reimbursement is usually higher for malignant growths, she says, so it makes sense to wait for the pathology report so you know which code most accurately describes the growth.

4. Understand starred procedures. A number of the codes for removing lesions are categorized as starred procedures within CPT. These include 11200, 11300, 11305, 11310, 17000, 17110, 17250, 17260, 17270 and 17280. Hill points out that a starred procedure is exempt from the usual surgical package limitations. Basically, a starred procedure code represents the surgical service only. Any pre- or postprocedural services may be reported in addition to the procedure code.

Coders should be aware that starred procedures may be billed in addition to codes that reflect office visits that occur on the same date of service.

If, for instance, the physician removes a wart from a long-time patient during an office visit in which other significant identifiable services were provided, coders would report the removal of the wart (e.g., 17110*, destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions) along with the appropriate evaluation and management (E/M) code (e.g., 99213, office or other outpatient visit, established patient). The E/M code would be appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Similarly, if the warts were removed during an initial visit with a new patient and the removal constituted the major service provided, 17110 would be reported. However, instead of the new patient office visit code, family practices would assign 99025 (initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit).

5. Recognize Medicare rules regarding global surgical periods. Although CPT categorizes a number of these codes as starred procedures, coders must recognize that Medicare may handle them differently. In fact, Medicare has assigned global-surgical package days in many circumstances. Starred procedure codes 11200, 17000 and 17110, for instance, have a 10-day global period. Code 113000 is also a starred procedure, but Medicare has assigned a 0-day global period to it.

Other, non-starred procedures are also covered by Medicare global period rules, including 11400 and 11600, each with a 10-day global period.

6. Code several lesions carefully. When the family physician removes several lesions in one session, coders may be confused about how to report the services appropriately.

If two or more lesions of the same size are removed from the same anatomical site, one code would be reported, with the appropriate number of lesions noted in the units box, Hill explains.

She adds, however, that often two lesions will be removed from different parts of the body perhaps one from the back and the other from a foot. If both are removed using the same technique (i.e., excision), both would be reported with modifier -51 appended to the service with lower reimbursement rates. If each is removed using a different method (i.e., one shaved and the second excised), however, both codes would be reported with modifier -59 (distinct procedural service) assigned to the service with lower relative value units.

Hill notes that physicians should not reduce their fees when using the -51 modifier because it may cause payers to automatically reduce the charge.