When Measuring Skin Lesions

Be Complete, Be Timely

By G. John Verhovshek, MA, CPC

Recently, reader Jennifer Huff, RN, CPC, wrote to Coding Edge with several important questions regarding lesion excision procedures 11400-11646:

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  • “In our physician’s documentation, we see lesion measurement in the office as ‘3 cm x 2 cm.’ Rarely, if ever, do we see anything that suggests margins. Can you tell us what you would do in this situation?”
  • “In the hospital operating room (OR) we will see margins, but it is from the pathology report (usually from a frozen section). I believe it is acceptable to add the margins from the path report to the lesion measurement. Is that correct?”
  • “From the standpoint of measurement, if the measurement isn’t obtained prior or during the procedure, is it acceptable to use the measurement from path report? The more explanation you can give on excision the better.”

The payment difference between 11403 and 11404 is small—approximately $10, on average, for Medicare payers—but over time these amounts can really add up.

Communicate Your Concerns

Jennifer’s questions point to a vexing problem coders often face: Adequate documentation from a clinical standpoint does not always provide the information necessary to code with precision. In such cases, coders need to communicate. Physicians may not realize what details a note should contain to code a particular procedure, but are quick to make adjustments if you explain what’s at stake.

Document Everything

The simple fact is: You can’t code what’s not documented. The lesion excision codes are size-based, with margins factored into the measurement. If the physician does not record the size of the margin taken, in addition to the size of the lesion itself, you cannot include the margin in your code choice. This means, most likely, the physician will not get the full reimbursement deserved.

Consider Jennifer’s example of a lesion documented as 2 cm x 3 cm. Let’s assume this is a benign lesion of the trunk. Without knowing the margins, you can only say with certainty that the lesion at its largest diameter is 3 cm. As such, you must report 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3 cm. If, however, the physician had documented “2 cm x 3 cm lesion with 0.5 cm margins on all sides,” you could report instead 11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm. CPT® specifies that to find a final measurement, you add together the largest diameter of the lesion, plus twice the smallest margin (3 cm + 0.5 cm x 2 = 4 cm).

The payment difference between 11403 and 11404 is small—approximately $10, on average, for Medicare payers—but over time these amounts can really add up. Perhaps more substantially, complete documentation makes for a more precise patient record, which benefits both the patient and the practice.

Take Appropriate Measures

All measurements should be taken prior to excision because a specimen subject to pathology may shrink or otherwise deform. Measurements from the pathology report are better than nothing, but they are not as accurate as measurements taken prior to excision. Once again, a shrunken specimen means a smaller measurement, and quite possibly a lesser code with reimbursement lost.

G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.

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