Primary Care Coding Alert

Question: An FP performs a level-two E/M on a new patient, during which she discovers a pair of lesions on the patients right hand. One of the lesions was 0.5 cm, and the other was 0.3 cm; the injuries were 1.0 cm apart. Using a scalpel, the NPP removes both lesions with one excision. Should I report one or two excision codes for this procedure?

Indiana Subscriber

Answer: Since the NPP performed both excisions with a single incision, you should group the excisions together and report one code for both.

Because the provider excised multiple lesions with the same excision, you should add the lengths of the two excisions to the margin between the lesions, and choose a code based on that length. (In your scenario, 0.5 + 0.3 + 1.0 = 1.8 cm.)

On the claim, report the following:

" 11422 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) for the excision

" 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) for the E/M

" Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M and excision were separate services

" 709.9 (Unspecified disorder of skin and subcutaneous tissue) appended to 11422 and 99202 to represent the patients injury.