Primary Care Coding Alert

No fewer than six distinct factors impact coding for wart removal, and each element has a significant bearing on payment. Warts are usually benign growths and, because removal is often viewed as a routine procedure, family practices sometimes assign the same sets of codes without considering ways to maximize their reimbursement. The following questions may assist coders as they review documentation and determine which codes are most advantageous to assign.

1. What is the method of removal? Warts are almost always removed by destruction, described in the 17000 series of CPT Codes . Methods of treatment include cryosurgery, laser, chemical treatment and electrosurgery. On occasion, if the physician suspects that a wart-like growth may be something other than a wart, the lesion may be excised and biopsied. Excision codes are found in the 11000 section of CPT and are assigned according to the method used, the site of the excision and, in some cases, the number of warts removed.

Family practice coders should note that if warts and other lesions are removed from different sites, destruction and excision codes can be billed on the same date of service. For example, if a physician excises a growth on a patient's arm, but destroys a series of warts on the patient's foot, codes from both the 17000 series and the 11000 series can be reported.

2. What type of wart has been removed? The physician must document the specific type of wart being removed because that determination could have a substantial impact on reimbursement. "There is often some misinterpretation about what is a common wart, a plantar wart and a flat wart," explains Laura Pettigrew, RHIA, CCS-P, CPC, training and auditing coordinator for Methodist Medical Group, which provides coding services to 96 physicians around Indianapolis. Nonetheless, she says, this is an important distinction to make.

Because 17110* (destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions) and 17111 (... 15 or more lesions) specifically mention flat warts in their descriptions, many practices automatically assign them for all wart removal. However, three other codes, 17000* (destruction by any method, including laser, with or without surgical curettement, all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions, including local anesthesia; first lesion), 17003 (... second through 14 lesions, each [list separately in addition to code for first lesion]) and 17004 (... 15 or more lesions), may be assigned for common and plantar wart removal -- and may result in greater reimbursement when multiple lesions are destroyed. In fact, the parenthetical comment following the definition for 17111 directs coders to use 17000, 17003 and 17004 for plantar or common warts.

3. How many warts were removed? The number of warts removed may greatly impact the codes assigned -- and the resultant payment. This is particularly the case when reporting the destruction of common or plantar warts, as opposed to flat warts.

The flat wart destruction codes, 17110 and 17111, describe removal of multiple warts. In other words, coders would assign 17110 once when the physician removes one to 14 warts. If more than 14 flat warts are destroyed, coders would assign 17111 once.

However, CPT allows destruction codes for multiple common or plantar warts to be assigned multiple times. Code 17000 would be assigned for the first wart and add-on code 17003 would be assigned for each subsequent wart removed up to 14, Pettigrew says. In other words, if the patient presented with eight plantar warts, coders would report 17000 once and 17003 seven times.

The difference in reimbursement is dramatic. In Florida, for instance, Medicare pays $61.19 for the flat wart code, 17110. However, it pays $60.15 for 17000 and $14.63 for each unit of 17003. Therefore, if a coder mistakenly reported 17110 for the removal of eight plantar warts, the practice would receive only $61.19. However, if the coder correctly reported 17000 once ($60.15) and 17003 seven times ($102.41), the practice would be paid $162.56. Precise payment will vary from region to region and carrier to carrier.

Coders should also recognize that if 15 or more lesions are destroyed, the entire procedure would be reported once, using 17004. In Florida, this code reimburses about $200.

Pettigrew cautions coders not to apply this coding convention universally to the removal of other types of lesions. "With skin tag removals, for example, you use 11200* [removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions] and 11201 [... each additional ten lesions (list separately in addition to code for primary procedure)] with a unit of one each for up to 25 removals. If 20 skin tags are removed you should code 11200 with one unit and 11201 with one unit." 

4. Does location and size of the removal matter?  On the rare occasions when wart-like lesions are removed by excision, the location and size of the growths are critical to correct coding. However, these elements are not a factor when warts are destroyed because those codes are not site- or size-specific.

"One of our biggest problems is that the coders tend to go to the first section of the excision codes, which is for trunk, arms and legs, and they don't pay attention to the exact site," Pettigrew says. Coders need to review documentation to determine if they should use 11400 (excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 0.5 cm or less) or 11420 (excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less).

Once coders have identified the correct site, the excision codes are determined solely on the diameter of the lesion. If the physician does not provide the size of the excision, coders are forced to use the first and least valuable code in the series. It is also important to explain to physicians that only simple closures are included in the excision. If a large lesion is removed, and an intermediate or complex closure is required, physicians can get paid for that closure if they provide the documentation to support the 12031-13160 codes (repair, intermediate and complex).

Note: An in-depth look at excision coding can be found in the November 2000 issue of Family Practice Coding Alert, "Multiple Factors Help Determine Correct Code For Reimbursement for Lesion Removal."

If a wart-like lesion is excised, codes should be chosen based on whether the growth is benign, premalignant or malignant. Benign or premalignant lesions that are excised will be reported with the 11400 series (excision -- benign lesions), while malignant lesion would be reported with the 11600 series (excision -- malignant lesions). In some cases coders will be required to wait for a pathology report to determine whether the wart is malignant before assigning the proper code, explains Deepa Malhotra, CPC, director of coding at Health Care Information Services, a physician billing company in Willowbrook, Ill.

She adds that coders sometimes mistakenly report both a biopsy code (e.g., 11100, biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and an excision code (11600 series) when a growth proves to be cancerous. "This isn't correct," Malhotra says. "If the physician biopsies a lesion, sends it to the lab for a report and then excises it once it is shown to be malignant, only the excision may be billed." She notes that, of the two procedures, the excision provides the higher reimbursement.

5. Can an E/M service be coded? Coding experts say yes, as long as the criteria are met and a separate exam is performed. "If our physicians actually evaluate the warts or examine the patient for another problem, we are able to bill the office visit in addition to the removal. Of course, this would require that the -25 modifier [significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service] be appended to the E/M code," Pettigrew explains.

For example, a young patient presents with a sore throat and during the visit the mother asks the physician to look at a wart. The physician examines the wart and decides to destroy it.

Coders should be aware, however, that there does not need to be a second problem or a different diagnosis involved. If the patient comes in solely to have the wart examined and the physician documents all criteria for an E/M service, the E/M service can be reported in addition to the wart removal code.

6. What about follow-up treatment? Whether a practice can bill a follow-up visit depends on the circumstances.

"Sometimes, a wart will need to be retreated after four or six weeks," says Pettigrew. This would be typical, for instance, after the destruction of a common wart (17000). "If this is the case, the practice could bill the applicable removal codes again. No modifier would be required. However, unless the patient presented with a separate problem, coders could not assign another E/M code because the physician would already have evaluated the warts in a previous visit."

Coders should note that some of the wart removal codes have global periods -- 17000, for instance, has a 10-day global period. During this time, any normal care would be included in the original service. "If the patient came back after five days because of itching or irritation, the practice could not bill an office visit," Pettigrew says. "This would be viewed as regular follow-up care within the global period."