Primary Care Coding Alert

Diagnosis coding: For skin tags, the common diagnosis code is:

• L91.8 (Other hypertrophic disorders of the skin)

For this type of lesion, payers may require reporting a secondary ICD-10 code to support the medical necessity of skin tag removal. For instance, you’ll find this rule in Noridian Healthcare Solution’s local coverage article “Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs” (www.cms.gov/medicare-coverage-database/view/ article.aspx?articleId=57161. Other payers may similarly require an additional diagnosis to cover skin tag removal. Therefore, a common error is reporting L91.8 alone. Payer policies may specify which codes support medical necessity, but some possible secondary ICD-10 codes are:

• R20.0 (Anesthesia of skin)
• R20.1 (Hypoesthesia of skin)
• R20.2 (Paresthesia of skin)
• R20.3 (Hyperesthesia)
• R20.8 (Other disturbances of skin sensation)

Procedure coding: Report skin tag removal with one or both of the following CPT^® codes:

• 11200 (Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions)
• +11201 (Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure).

Though not mentioned in the descriptors, these codes include most traditional removal methods, including removal by scalpel, ligature strangulation, or chemical/electrical cautery, as described by the CPT^® guidelines for the codes. The thing to pay attention to here is how many lesions the practitioner removed during the visit. “Report 11200 for the first 15, and +11201 for each additional 1-10 skin tags. Reporting +11201 requires that the physician remove a minimum of 16 lesions in total. You cannot report +11201 without also using 11200 on the same claim,” explains Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Note: “Reporting removal of more than 25 skin tags in one session is considered medically unlikely, and a clinical NCCI [National Correct Coding Initiative] medically unlikely edit (MUE) of 1 has been established for code +11201,” says Pohlig. “The MUE Adjudication Indicator (MAI) for +11201 is 3 however, so it is possible for Medicare administrative contractors to pay units of service in excess of the MUE value if the denial is appealed and there is adequate documentation of medical necessity of correctly reported units,” Hall adds. You can find this information in Chapter I.V of Medicare’s National Correct Coding Initiative Policy Manual.

Warts: Turn to 17110, 17111

Diagnosis coding: The four most common ICD-10 codes associated with wart removal are:

• A63.0 (Anogenital (venereal) warts)
• B07.0 (Plantar wart)
• B07.8 (Other viral warts)
• B07.9 (Viral wart, unspecified)

Procedure coding: Turn to one of the following CPT^® codes for wart removal:

• 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions)
• 17111 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions)

Be careful. Unlike the procedure codes for skin tag removal, “it is incorrect to report both 17110 and 17111 if the PCP removed 16 lesions,” says Pohlig. Report only one code or the other based on the number of lesions destroyed on the date of service. According to the NCCI Procedure-to-Procedure edits, the codes are bundled, which means 17111 (which represents destruction of 15 or more lesions) includes the first 14 lesions otherwise represented by 17110. The edit makes sense because it is consistent with the CPT^® descriptors for the two codes.

Coding alert: Sometimes, warts can present with a raised, callused area that the practitioner would shave down prior to the administration of the destruction agent. However, pairing 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) with 17110 for the same treatment location is not appropriate. “This is considered as double-dipping. The paring of the lesion is considered to be part of the overall treatment for the removal of the wart with liquid nitrogen so therefore, we would only be able to bill CPT^® 17110 and not in addition to 11055 for the same treatment area,” Hall explains. Not coincidentally, NCCI edits bundle the two codes unless the edit is appropriately overridden with a modifier, such as modifier 59 (Distinct procedural service) to indicate separate lesions.

Inflamed seborrheic keratosis (ISKs) or other seborrheic keratosis (SKs): Turn to 17110, 17111

Diagnosis: Report one of the following ICD-10 codes for these lesions:

• L82.0 (Inflamed seborrheic keratosis)
• L82.1 (Other seborrheic keratosis)

For inflamed seborrheic keratosis (L82.0), many payers consider that diagnosis sufficient to justify the medical necessity of destruction. However, for other seborrheic keratosis, just like with skin tags, some payers may require the use of secondary codes, such as the R codes mentioned in the skin tags section.

Procedure: For destruction of ISKs and SKs, choose from 17110 and 17111 just as you would for warts.

Actinic Keratosis (AKs): Turn to 17000, +17003, 17004

Diagnosis: In most cases, report the following diagnosis code for AKs:

• L57.0 (Actinic keratosis)

Be aware of the Use additional note that applies to the L57.- group of codes. It instructs you to identify the source of radiation, such as:

• W89.- (Exposure to man-made visible and ultraviolet light)
• W90.- (Exposure to other nonionizing radiation)

Procedure: Choose one or more of the following CPT^® codes for removal of definable AK lesions:

• 17000 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion)
• +17003 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion))
• 17004 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions)

The number of lesions comes into play as it did with 11200 and +11201. However, you report these codes a little differently than how you would report the skin tag codes. “For example, if the provider treats a total of seven AK lesions, this would be coded as 17000 x 1 unit and +17003 x 6 units. The combined units would equal out to seven total AK lesions. If the provider treats a total of 15 or more lesions, this is when 17004 is billed as one unit. It doesn’t matter if the provider treats 35 AK lesions. It would still be reported as just 17004,” Hall explains.

Know When to Append Modifier 59

When the patient has multiple skin tags on their neck in addition to a couple of stubborn warts on their foot, or a patient comes in for treatment of a couple of AKs in addition to a few ISKs, you should append modifier 59 (Distinct procedural service). Many coders append modifier 59 to whichever codes have the lower relative value units (RVUs). Code “17110 has 3.37 total RVUs in the nonfacility setting, 17000 has 1.99 total RVUs, and +17003 has a total RVU of 0.20. This will therefore be coded as 17110 x 1 unit, 17000 x 1 unit + modifier 59, and 17003 x 1 unit + modifier 59.,” says Hall.

Note: “Errors commonly occur without knowing all of the procedural details,” Pohlig says. If the provider’s notes aren’t clear, the coders have the opportunity to educate providers on how documentation affects coding.