Primary Care Coding Alert

Question: A patient presents for a family physician to remove four nevi. The FP excises the first nevus, which is 0.8 cm including margins, from the back, and pathology comes back atypical.

The physician excises the second nevus from a different area on the back. Pathology comes back atypical. Size is 0.8 cm.

The FP removes the third nevus from the back. Pathology comes back as a compound nevus. Size is 0.6 cm.

The physician takes the fourth nevus off the arm. It comes back as a compound nevus and the size is 0.6 cm.

We sent four biopsies to pathology. The doctor also treats the patient for hypertension and anxiety. Should we use these codes?:
  11401 dx 238.2
  11401-51 dx 238.2
  11401-51 dx 216.5
  11401-51 dx 216.6
  88305 4 units dx 238.2, 216.5, 216.6
  99213-25 dx 401.1, 300.02.


Texas Subscriber


Answer: You should make two changes before submitting the claim.

1. Modifier: You should use modifier -59 (Distinct procedural service), not -51 (Multiple procedures). To indicate that the excisions occur on separate sites, you should append modifier -59 to the subsequent excisions (11401, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.6 cm to 1.0 cm).

2. Pathology: Check whether you really performed the pathology. You should only report 88305 (Level IV - Surgical pathology, gross and microscopic examination) if the FP reads his own slide and purchases the tests - and then only for non-Medicare patients. Because you indicate "the pathology comes back," you probably sent the specimens out for study. In this case, you shouldn't bill any units of 88305.

Despite those changes, you are probably correct in separately coding an E/M visit, such as 99213 (Office or other outpatient visit for the E/M of an established patient) for the hypertension (401.1, Essential hypertension, benign) and anxiety (300.02, Generalized anxiety disorder) evaluation and treatment. You would then appropriately use modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to describe a significant, separately identifiable service from the nevi removal.

You solidify your E/M claim with separate diagnoses. The E/M is for the hypertension and anxiety. The removals are for each of the pathology-returned diagnoses: 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin), 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum) and 216.6 (... skin of upper limb, including shoulder).

Lurking problem: The statement "We sent four biopsies to pathology" could confuse a coder. Although you will usually send specimens to pathology, biopsy implies 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).
 
Encourage your FP to reserve the term for [...]