Skin Lesion Excisions

Skin Lesion Excisions

Three answers in the report will help you piece together the coding puzzle.

To accurately code for excision of a skin lesion, you need to be able to extract from the documentation the answers to three very important questions:

  1. Was the lesion benign or malignant?
  2. Where was the lesion located (anatomic site)?
  3. What was the excised diameter of the lesion?

Let’s examine how these parameters are determined, and how they affect your code selection.

Determine Classification

Excision codes fall into two main classifications: Those describing benign (non-cancerous) lesions and those describing malignant (cancerous) lesions.

Per ICD-9-CM Official Guidelines for Coding and Reporting (chapter 2: Neoplasms), “To properly code a neoplasm it is necessary to determine from the record [e.g., pathology report] if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior.”

If the pathology report describes a benign lesion, or one of uncertain behavior (e.g., indications of atypia or dysplasia), you must use a benign lesion CPT® code (11400-11446).

To assign a malignant lesion CPT® code (11600-11646), the pathology report must confirm a malignancy, which may be primary (malignancy at the site where a cancer begins to grow), secondary (malignancy has spread from the primary site to other parts of the body), or in-situ (an early-stage tumor that may evolve into an invasive malignancy).

Be certain that your code selection is backed up by the pathology report, even if that means holding the claim for a few days. If you don’t have a pathology report to confirm the diagnosis, you must assign an unspecified diagnosis and a benign lesion excision CPT® code (11400-11471). The only legitimate exception to this rule is if the provider performs a re-excision to obtain clear margins at a later operative session. In such a case, report the same diagnosis as that used for the initial procedure.

Determine Location

Report each lesion excision independently, using the following site-specific classifications:

Benign lesion

  • Trunk, arms, legs – 11400-11406
  • Scalp, neck, hands feet, genitalia – 11420-11426
  • Face, ears, eyelids, nose, lips, mucous membrane – 11440-11446

Malignant lesion

  • Trunk, arms, legs – 11600-11606
  • Scalp, neck, hands, feet, genitalia – 11620-11626
  • Face, ears, eyelids (skin only), nose, lips – 11640-11646

Determine Size

Size is of primary importance when reporting lesion excision. Per CPT®, “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision.” The margin is further defined as “the most narrow margin required to adequately excise the lesion ….”

In plain language, the excised diameter equals the length of the lesion at its longest point, plus two times the narrowest margin. For example, if the lesion measures 1 cm at its greatest, and the surgeon removes a margin of 0.5 cm on all sides, the total excised diameter is 2.0 cm (1.0 cm + [2 x 0.5 cm]).

Your physician should measure the lesion plus margin before the excision. Do not select codes based on the size of the incision and/or the resulting surgical wound.

Put It All Together and Code It

When you have the facts—classification, location, and size—you are ready to code the service. Here are a few examples of how you might use the information to determine proper coding.

Example 1: A surgeon excises a malignant lesion from a patient’s right shoulder. Prior to excision, the lesion measures 1.0 cm at its widest. To ensure removal of all malignancy, the surgeon allows a margin of at least 1.0 cm on all sides, for a total excised diameter of 3.0 cm (1.0 cm + [2 x 1.0 cm]).

The correct code is 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm.

Example 2: The surgeon removes a single lesion from the left cheek. The lesion measures 1.5 cm at its widest, around which the surgeon removes a margin of 0.5 cm. The pathology report reveals a neoplasm of uncertain behavior.

“Uncertain behavior” requires you to report benign lesion excision (11400-11446). The location is the cheek, which narrows your choice to codes 11440-11446. The total excised diameter is 1.5 cm (the lesion itself) plus twice the margin (2 x 0.5 cm = 1.0 cm), or 2.5 cm.

The correct code is 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm.

Multiple Excisions Require a Modifier

Treat each lesion excision as an individual and separate procedure, and link a verifiable diagnosis to each individual CPT® code for multiple excisions. Append modifier 59 Distinct procedural service to the second and subsequent codes describing excisions at the same location to avoid duplication denials.

Example 3: The surgeon removes three lesions from the left arm, with total excised diameters of 0.5 cm (benign), 1.5 cm (benign), and 2.0 cm (malignant). Proper procedure and diagnosis coding is:

11602 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 173.6 Other malignant neoplasm of skin, skin of upper limb, including shoulder

11402-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 216.6 Benign neoplasm of skin; skin of upper limb, including shoulder

11400-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less with 216.6.

“Re-excision” Calls for Special Consideration

The physician may revisit a previous excision to remove additional material if pathology continues to show malignancy in the margins. How you report this depends on the timing of the follow-up excision.

If the re-excision occurs during the same session as the initial excision, report a single code to describe the greatest area removed. For example, if the first excision measures 3.0 cm with margins, and the second excision increases the margins by 1.0 cm on all sides, code for a 5.0 cm excision. Do not separately report a 3.0 cm excision and a 5.0 cm excision.

If the re-excision occurs during a subsequent session, however, base your code selection on the diameter of the new excision. For example, you report 11603 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm for the initial excision on Tuesday. Pathology indicates inadequate margins to remove all malignancy. The physician returns the patient to the procedure room three days later (Friday) and increases the margin by 1 cm on all sides. You report Friday’s session using 11606 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter over 4.0 cm, with modifier 58 Staged or related procedure or service by the same physician during the postoperative period appended because the re-excision occurred during the global period of the initial excision.

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Excision Differs From Shaving, Destruction

In addition to the skin lesion excision codes (11400-11646), CPT® also includes codes to describe lesion removal by shaving (11300-11313), destruction (17000-17004), and paring or cutting (11055-11057). A few simple definitions distinguish between these various procedures.

CPT® defines excision as “full-thickness (through the dermis) removal of a lesion including margins …” An excision is performed with a scalpel held perpendicular to the skin, and involves cutting into the subcutaneous tissue to remove the entire lesion.

By contrast, CPT® defines shaving as “The sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full thickness dermal excision.” In other words, the physician uses a scalpel, placed horizontally to the patient’s skin, to slice off a piece of the lesion.

Paring or cutting describes the removal of superficial tissue using a spoon-shaped surgical instrument called a curette (credit armondo). This procedure is also called curettement.

Lesion destruction occurs via laser surgery, electrosurgery, or other methods (but not a scalpel). Always expect a diagnosis of 702.0 Actinic keratosis with the premalignant lesion destruction codes (17000-17004).

 

Lesion Excision Bundling Concerns

When reporting excision of skin lesions (11400-11646), in addition to other procedures at the same anatomic location during the same session, be on the lookout for the following bundling issues.

Do not report in addition to lesion excision:

  • Local anesthesia
  • Simple closures (12001-12018)

Report in addition to lesion excision:

  • Intermediate (12031-12057) and complex (13100-13153) repairs
  • Reconstructive closure (15002-15261, 15570-15770)

Do not report lesion excision in addition to:

  • Adjacent tissue transfer (14000-14350)

 

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

7 Responses to “Skin Lesion Excisions”

  1. Marci Nablo, CPC, OCS says:

    Hello John,

    I have a question and I am not certain that this is where I ask my question. I have a physician that frequently does shave excisions, 11300-11313. When determining the total cm’s, do you list each lesion separately? Or do you add the total cm’s by body area?

    Say, for example, you have five lesions on the back and each are 1.2 cm’s. Do you list 11302 (1.1 to 2.0 cm) five times, or do you total all five lesions = 6.0 cm’s and use the 11303 ( >2.0 cm’s) one time?

    Can you please clarify or direct me elsewhere?

    Thank you so much.

    Marci

  2. Elizabeth says:

    We also have pre-malignant codes (17000-17004). When are they used?

  3. Sendy says:

    I have a problem understanding about a code.
    wide excision of a malignant lesion of back (5.0 x 3.0 cm) with adjacent skin graft
    Does anyone know what the code would be for this and what would you look up to come to the code in the alphabetic index.

  4. Mark G Massar says:

    Mr. Verhovshek,

    I am a patient who’s surgeon is billing me for 11602 & 12032.
    While i cannot contest the cost/benefit of the actual medical need for 12032 over 12002 (to reduce necrosis, infection and dehiscence in an area of the body not subject to little if any stress),
    we are having a debate over whether he (staff actually) is entitled to the entire payment component of a simple repair (which I am willing to limit to the facility RVU assignment, in other words just that part of 12002 which is the surgeon’s time) plus the entire payment of an intermediate repair.

    If $70 of the $174 is for the surgeon’s time to repair the simple wound created by his knife, is he then also entitled to the entire $213.05 for the intermediate repair for a total of $283.05 when a patient presenting themselves for a repair of a wound not resulting from the surgeon’s blade in an intermediate repair would only receive $213.05?

  5. Sara De La Cruz says:

    I still have a question on coding 17003.
    There seems to be different ways that coders are billing this.
    As I read the code description, I say we have to enter the unit # that were destroyed.
    Examples: 10 were destroyed so I billed 17000, then 17003 x 9.
    Is this the correct way?

  6. ASaiz says:

    You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  7. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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