Urology Coding Alert

Hint: Lesion type guides your decision on coding from the 54050 series or not.

If your urologist sees a patient who presents with a penile lesion, the coding choices are more wide-ranging than you may think. CPT^® includes separate sections for dermatological excision and destruction versus penile lesion excision and destruction, but coders can easily pinpoint the right choices with a few key tips.

Check out the following three scenarios, along with guidance on how to appropriately report these services.

FAQ 1: Can You Differentiate Excision Codes?

Conundrum: When the urologist’s documentation notes that they performed penile lesion excision, you might immediately reach for 54060 (Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision). But many coders ask how they can choose between this code and 11424 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm), since both refer to “excision.”

Solution: To understand which code suits the situation, you should first read more deeply into the documentation so you can confirm the specific type of lesion the urologist addressed.

Opt for 54060 if the urologist excised lesions such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicles (as stated in the definition of the code). Medicare reimburses about $201 for this code if the urologist performs it somewhere other than a facility, like a physician’s office.

If, however, the urologist excised other skin lesions, such as sebaceous or epidermal cysts, you’d instead report 11424. You’ll collect about $242 for this code if the urologist performs in the excision in a nonfacility location, such as your office.

Without appropriate documentation, you won’t be able to accurately differentiate between the two codes, so query the urologist if necessary. In this case, it may also be a good opportunity to provide the physician with a short primer on the importance of thorough documentation.

FAQ 2: What’s a ‘Simple’ Cryosurgery?

Conundrum: When your urologist performs cryosurgery to destroy penile lesions, the documentation is usually pretty clear about the fact that they used cryosurgery as the method. What they may not be as clear about, however, is whether the procedure was considered simple or complicated, which will dictate which code you can report.

Solution: You won’t find a specific answer in CPT^® or in local coverage determinations (LCDs) on the number or size of lesions that qualify you to report 54056 (Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery) or 54065 (Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)), so only the urologist can make that call.

Typically, the urologist will select 54056 if they destroy just a few lesions and the destruction of the lesions is considered simple. The urologist should identify the simple destruction in the operative note, says Stephanie Stinchcomb Storck, CPC, CPMA, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland. The simple destruction description could be based on the size and depth of the lesions.

If, however, the urologist destroys a large number of lesions or the destruction is more extensive due to the larger size of the lesion or lesions that are deeper in the tissue, you’ll report 54065 rather than 54056, Storck advises. Asking your payers for guidance may be helpful if the urologist isn’t sure which to report, but in most cases, the physician can help you select the right code if the documentation doesn’t guide you to one clear choice.

FAQ 3: Can You Code Lesion Destruction for Accompanying Areas?