Primary Care Coding Alert

Hint: Number of lesions govern the code you select for the procedure.

You may often find your FP performing excision or destruction of lesions such as warts, premalignant and even malignant lesions. While reporting for various removal methods, such as shaving or excision, or destructions may not be simple as it seems to be, you also need to be aware of not falling prey to these myths.

Myth 1: There is no real difference between shaves and excisions.

Reality: There are many differences, in the complexity of the procedures and the reimbursement they bring.

Thickness matters: To distinguish between shaving and excision, one useful piece of data is the thickness of the skin your FP removed. The shaving CPT® codes, 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…) describe removal of the lesion down to the middle dermis, without a full-thickness dermal excision disturbing the subcutaneous tissue.

The excision CPT® codes, 11400-11646, describe full-thickness removal of the lesion that can extend into subcutaneous tissue, says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas.

Note the method: During shaving, your clinician will use a horizontal slicing motion to remove the lesion. Your FP will then hold the blade horizontal to the skin and moves it across the lesion, literally shaving it off. There is usually no need for suture closure or a repair code.

Excision, however, usually involves holding the blade perpendicular to (and thus cutting through) the skin with an elliptical, wedge, or circular incision to remove the lesion at a greater depth – for which a scalpel is better suited. In these cases, your clinician always wishes to remove the entire lesion to the greatest necessary depth. Excisions may require surgical closure.

Payment reflects difficulty: The CPT® code for shaving of a single lesion from the trunk less than 0.5 cm in diameter, 11300 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less), is approximately $98.10 in a non-facility setting (2.74 relative value units (RVUs) multiplied by the $35.8043 conversion factor).

By contrast, the CPT® code for excision of a benign lesion of similar size and location, 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) is $125.32 (3.50 RVUs), showing that Medicare values the work that goes into excision more than shaving.

“The difference in relative value and payment also reflects a difference in the global surgical period assigned to each code,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Code 11300 has a zero-day global, meaning the relative value and payment include only what occurs on the day of the procedure. In comparison, code 11400 has a 10-day global period, so it includes normal post-procedure for a period of 10 days rather than just the day of the procedure itself,” Moore adds.

Biopsies matter – sometimes: Whether or not sending a sample to pathology will affect your CPT® code choice depends on your clinician’s intent. Often, your FP may shave a lesion he suspects to be benign and submit the tissue for biopsy. But in that case, you should still submit the appropriate shaving code instead of the biopsy code, because biopsy is included in the shave.

If your physician suspects a malignant lesion, he may shave off part of it to send to pathology, intending to excise the entire lesion later if pathology confirms that the tissue is malignant. Here, you would apply the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and, if required at a later session, the appropriate code for excision of malignant lesion procedure (11600-11646).

But even if the pathology report did not reveal malignancy in the above case, you would still report the biopsy code rather than a code for removal by shaving. In this case, the intent was to obtain sample tissue for examination, not removal.

Myth 2: You can code benign wart destruction per lesion.

Reality: No. If your FP destroys between one and 14 benign lesions, one unit of CPT® code 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) is the appropriate claim.

For 15 or more lesions, the proper code would be one unit of CPT® code 17111 (…15 or more lesions).

That’s true even if you destroy warts from multiple sites, say experts. The code descriptors specify the total number of lesions removed, but don’t specify anatomical site. So your count can include warts from multiple areas.

Don’t miss: You also can’t report CPT® codes 17110 and 17111 together. If your clinician destroys a total of 14 or fewer warts, report 17110; if he destroys a total of 15 or more, report 17111.

Myth 3: Premalignant and benign are interchangeable.

Reality: No, a benign lesion is self-contained and does not have the potential to spread to other parts of the body. A premalignant lesion, while not yet malignant, is by no means benign. A premalignant, or precancerous, lesion has the potential to spread to other areas, but its growth has not yet become uncontrolled.

As a result, you should not confuse the benign lesion destruction codes (17110-17111), which would be appropriate for wart removals, with CPT® codes 17000-17004 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses] …). You should note that these codes are strictly applicable to premalignant lesions, and warts do not fall into that category.