Coding Pearls for Skin Care Challenges
By Stephen C. Spain, MD, FAAFP, CPC
The surgical treatment of common skin lesions is an important source of revenue for most family practice offices. Because skin treatment coding is complex, it’s important for a coder to understand the different procedures and the common skin lesions their providers treat. Familiarize yourself with the following skin treatment services and supporting codes to help you select the proper CPT® code(s) and modifiers for correct billing and maximum reimbursement in a family practice.
Surgical Package Guidelines
The CPT® surgical package definition is found in the forward of the CPT® Surgery Section. As outlined in the definition, the skin procedure codes include any pre-procedure preparation, as well as the required local or regional anesthesia. Routine follow-up care is also included as part of the surgical package. Note: Laceration repair is not billed separately for the closure of simple wounds created as a result of a minor surgical procedure on the skin.
If multiple separate procedures are performed on the skin, be sure to append modifier 59 to additional procedures. For example, if a physician performs a shave biopsy of a 0.5 cm mole on the arm at the same time 10 skin tags are removed, code 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less and 11200-59 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions—Distinct procedural service. When the same procedure is repeated multiple times, either modifier 51 Multiple Procedures or modifier 76 Repeat procedure or service by same physician may be appropriate. If a shave biopsy is preformed on three arm lesions, two of which are 1.1 cm in size, and the third 0.5 cm in size, code as 11302 lesion diameter 1.1 to 2.0 cm, 11302-76 and 11300-51.
When an evaluation and management (E/M) service is allowed in addition to the skin procedure, coding for the skin procedure is often misunderstood. A new patient presenting for a skin procedure could qualify for an E/M service if their condition requires a separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure. If the skin problem is addressed in addition to the patient’s presenting problem, then an E/M code is appropriate for the presenting problem, whether dealing with a new or established patient. However, if a patient returns solely for the treatment of a previously diagnosed skin condition, and no other service is documented, billing an E/M code is incorrect. When billing an E/M service and a skin procedure together, many payers require that modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service is appended to the E/M code. Check with your local carrier when using this modifier.
Three key components for coding laceration repair correctly are complexity, location, and length. The complexity of laceration repair is generally determined by the depth of the wound and the amount of repairing required to mend the deeper layers of the wound. Most wounds fall into the simple or intermediate category. Wounds that do not require layered closure are considered simple, and these wounds encompass the majority of repairs in family practice. An intermediate repair requires suture placement inside the wound to approximate tissue layers below the skin. This is necessary in wounds that are particularly deep or gaping. When deep sutures are placed, they do not communicate with the skin and are not removed.
Selecting the proper laceration repair code is dependent upon wound location, and is explained in the 12000 section of the CPT® Surgery section. In the family practice setting, usually only a single repair is made. However, if more than one wound is repaired, the sum of the wound’s total length is reported with the appropriate repair code, and the coder should pay particular attention to the summation rules in the CPT® manual.
Routine cleaning and preparation of a repaired wound is included in the repair code. However, if a simple laceration requires extensive cleaning and debridement, the repair can raise to the intermediate level, per the CPT® guidelines. This ‘extra effort’ should be well documented in the record.
If laceration repair requires the use of excessive or unusual supplies, the necessary extra supplies should be well documented, and billed separately for supplies (for example, CPT® 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided), or another applicable code could be submitted. Reimbursement for supplies in this circumstance is usually made with appeal, and coverage for additional supplies varies among insurers.
In family practice, skin biopsies are generally a shave biopsy or a full thickness biopsy. A shave biopsy is a shallow scraping of the skin done with a sharp blade held nearly horizontal to the skin. The resulting skin defect is very shallow and is often treated with a chemical or electrocautery to control bleeding. In contrast, a full thickness biopsy involves cutting into the deeper layers of the skin. Usually, the resulting defect requires a suture or two for closure. This type of biopsy is often done with a scalpel or a special punch biopsy tool. A wedge or plug of the skin is removed and sent for pathology evaluation. Biopsies requiring suture closure are coded using either 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion or +11101 Each separate/additional lesion (List separately in addition to code for primary procedure) for the additional biopsies, and the shave biopsies would be coded with the CPT® 11300-11313 series of codes.
If a biopsy is part of another procedure, the biopsy code is not separately coded. For example, if a biopsy is part of a 1.1 cm neoplastic lesion excision on the forearm, only the excision code CPT® 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm is billed.
Incision and Drainage
Family practitioners frequently treat skin conditions that require skin incision and drainage of fluid (pus, blood, or serous fluid). These procedures are referred to as incision and drainage (I&D). I&D implies a sharp instrument (e.g., a scalpel blade) is used to open the skin and material is drained or removed. In most cases, the wound is irrigated and thoroughly cleaned before applying a dressing. Larger wounds may require the insertion and changing of packing daily, to allow the wound to drain and close before the skin edges heal over the wound cavity. The two codes covering most I&D services in family practice are CPT® 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single and 10061 complicated or multiple. Multiple lesions, or any lesion that requires progressive re-packing in the office or the management of systemic antibiotic therapy, could be considered complicated. There are separate I&D codes in the CPT® Surgery Section for foreign bodies, hematomas, puncture aspiration, and pilonidal cysts.
Skin tags, or dermatofibromas, are fleshy, pedunculated growths that can occur anywhere, but most often arise on the neck, axillae, or groin area. They are usually removed with electrodessication or with a scalpel or scissors. Frequently, local anesthesia is used for this procedure. Because skin tags generally occur in clusters, and are simple to remove, they are coded separately from the destruction of other types of skin lesions. The CPT® 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions code for skin tag removal includes the first 15 lesions removed. The CPT® +11201 … each additional 10 lesions (List separately in addition to code for primary procedure) code is used for each additional 10 lesions. For example, if 25 lesions are removed, code both 11200 and 11201.
Many skin lesions are recognized easily as requiring removal without needing a biopsy. Typically, this would include actinic keratoses (crusty areas of sun damaged skin), irritated seborrheic keratoses (a brownish, raised, benign skin growth), and warts. These lesions are often simply destroyed. Commonly, this is performed with cryotherapy (often using liquid nitrogen) or electrocautery (aka electrodessication). Often, keratoses and warts are multiple, and the precise count of treated lesions is necessary when selecting the correct codes.
Usually, moles and other skin lesions require complete removal, or excision. The proper code selection depends upon whether the lesion is benign or malignant, so coding often waits until the pathology report is available. Physicians usually document the lesion size, which may vary. Be sure your physician gives you the total size of the excision, including the margins of tissue removed plus the lesion width. This total size is used to determine the correct excision code. There are illustrations in the CPT® Surgery Section that explain this point.
In family practice, most lesion excisions involve simple repair, which is included in the excision code. However, if the repair is more complex, such as requiring a layered closure or moving adjacent tissue to cover the wound, a separate wound repair code may be applicable.
Communicate for Correct Coding
When applying coding rules to skin condition treatments, it’s important that the medical record give precise information about the condition treated. If the record is unclear, the door is opened for the coding staff to discuss the care and treatment with the provider. This discussion is a valuable opportunity for the coder to explain the documentation essentials for proper coding and payment. Working together in this way, health care providers and coding professionals achieve their common goals of reducing audit liabilities and enhancing practice revenue.
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- actinic keratoses
- Distinct procedural service
- family practice
- fibrocutaneous tags
- laceration repair
- layered closure
- liquid nitrogen
- malignant lesion
- modifier 25
- modifier 51
- modifier 59
- modifier 76
- neoplastic lesion excision
- postoperative care
- preoperative care
- repeat procedure
- seborrheic keratoses
- serous fluid
- shave biopsy
- simple repair
- skin defect
- skin tags
- skin treatment
- sun damage
- surgical package