Primary Care Coding Alert

The problem with lesion removal arises when family doctors confuse medical terms with CPT language, says Inga Ellzey, MPA, RRA, AHIMA, AAPC, chief executive officer of the Inga Ellzey Practice Group, a coding consulting firm in Casselberry, FL. They might use a term such as shave biopsy, but it cant be both. Even if a shaved mole is sent to the pathologist, its not a biopsy. Or they use biopsy excision. Its either biopsied or excised, she says.

The removal of lesions, which is a common procedure in family practice offices, triggers questions in several areas:

four different codes depending on how the lesion is removed;

proper measurement of a lesion to ensure apropriate coding;

codes related to re-excisions;

medically unnecessary versus medically necessary
lesion removals; and

coding for the removal of two lesions during one visit.

The four types of removal are:

1. biopsy (11100-11101): the partial removal of a lesion for the purpose of diagnosis. If a lesion goes to pathology, dont code until the results are back,
suggests Ronni Collins, CPC, a coding consultant with Berkeley Family Practice in Moncks Corner, NC, which has two physicians and three physician assistants. If the lesion is malignant, you can get a higher reimbursement.

2. shaving (11300*-11313): removes the entire lesion but does not penetrate through to the fat. Moles are the most common lesions to be shaved.

3. destruction (17000*-17250*, benign; 17260*-17286, malignant): lesions are usually destroyed by liquid nitrogen, laser or burning, as with warts.

4. excision (11400-11471, benign; 11600-11646, malignant): cuts are made through to the fat to remove the entire lesion. They generally require sutures.

James A. Zalla, MD, a dermatologist with Dermatology Associates of Northern Kentucky in Florence, chairman of the Academy of Dermatologys classification and coding task force, and a member of the CPT education panel, says to use caution and make sure you use the shave removal code when the incision does not go through to the fat and the code for excision if it does.

The type of removal has to be reflected in documentation, so not only do physicians have to choose the correct code, they also have to provide documentation to support it, Ellzey says. The four types warrant different levels of reimbursement, with excision being the highest, followed by most shaved lesions, then biopsy and destruction.

Size Does Makes a Difference

The coding for shaving, destruction and excision depends on the size and location of the lesion. Ellzey says many physicians just eyeball the size of a lesion, but even one millimeter can change the code and your reimbursement amount. She explains that the size is determined by the biggest of the measurements for the width, length and depth. But if you cut extra for diagnosis, you cant count that extra skin, she says.

Note: The size is based on the size of the lesion, not on the size of the incision.

If a lesion needs to be re-excised, the accepted standard by practitioners for size, Ellzey says, is based on the width. It in turn is multiplied by 2.5 to determine the length, which helps determine what codes to choose for closure. If lesions require sutures, repair codes (12001*-13300)simple, intermediate and complexare used. But if a lesion is 0.5 centimeters or smaller, you cant bill for a layered closure; you cant add a repair code, because its too small. Its considered unbundling and would send up a red flag, Collins says.

She also suggests that coders pay close attention to the repair codes and the subsections that explain them. You may want to just code for benign or malignant lesions, but there are codes for specific locations and sizes. The CPT manual is user-friendly, Collins says. She also reminds coders to use modifier -76, (a repeated service or procedure subsequent to the original procedure or service) if the re-excision is performed by the same physician.

More advice about excisions and suturing comes from Zalla: It is appropriate to charge for a surgical tray for excisions when the supplies are the physicians, but sometimes that charge gets bundled into surgery. Use HCPCS code A4550 (surgical trays) if you do charge, he says.

When is Lesion Removal Medically Necessary?

Medicare guidelines on lesions say they are medically necessary and reimbursable if they are symptomatic. Zalla suggests coders become familiar with their carriers policies on medical necessity. He believes that family physicians ought to be fair to carriers and that the removal of lesions that are not symptomatic should not be submitted for payment.

While some lesion removal is clearly medically necessary, as in the case of a malignant tumor (a pathology report must accompany the billing), removal of benign lesions may be considered necessary only under certain circumstances. For example, a patient with a mole on her lip wants to have it removed even though it has not changed for years in color or size and presents no danger to the patient. Most likely, the procedure will be deemed unnecessary. On the other hand, removal of a skin tag that constantly bleeds from being aggravated by a piece of clothing may be approved as necessary.

You can be charged with fraud or abuse if you charge for medically unnecessary procedures, but you can also be negligent if you do not charge for a medically necessary procedure just because it has a low rate of reimbursement, Ellzey says.

Two Lesions at One Visit

A patient has a lesion on both his back and foot, removal of both of which is considered medically necessary. They are removed during the same visit. Although both should be billed, 11401 (excision of benign lesion on trunk, arms or legs with diameter 0.6 to 1.0 cm) and 11421 (excision of benign lesion on scalp, neck, hands, feet, genitalia with diameter of 0.6 to 1.0 cm) respectively, attach modifier -51 to the second procedure or the one with the lower value. (According to CPT: When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedures or services may be identified by appending the modifier -51 to the additional procedure or service codes.)

If the two lesions are in the same area, however, Ellzey says to use a modifier -51 or -59, (which indicates that a procedure or service was distinct or independent from other services performed on the same day) for the second lesions removal or the carrier might think the second procedure is an accidental duplication. Appropriate coding for removal of two lesions at one visit is a carrier-specific decision.

Append modifier -51 to the procedure with the lower relative value if there are two lesions involved, adds Janie Detisch, business manager for Zallas practice. If not, when the claim is processed, payment for both procedures may be cut in half. You receive 100 percent for the most expensive procedure and usually 50 percent for the procedure with lesser value.

In addition, modifier -51 will cut payment in half, so putting modifier -51 on the most expensive procedure would reduce it by half, and the lesser procedure would also be reduced by half. For instance, if there is an excision of a malignant lesion with a complex repair, the closure code should get priority because it has the higher value, Collins explains.

She notes that some carriers will bundle the two procedures, saying the repair is a natural result of an excision. Family practitioners ought to bill 100 percent for both procedureseven if you append modifier -51because the less expensive procedure will already be reduced to only 50 percent and the modifier -51 will also cause a reduction of 50 percent, so payment could be 25 percent.