Explore Coding Complexities of Skin Procedures
Part 1: Consider skin lesion removal type and depth, intent, and lesion location to avoid common coding mistakes.
Accurately coding dermatological procedures can seem like a daunting task. Code selection can be confusing because skin procedure codes require you to consider several factors such as the type of removal, lesion size and location, pathologic results, intent, etc.
At HEALTHCON 2019, Melissa Caperton, RHIA, CPC, CPMA, CPPM, CFPC, Approved Instructor, presented on how to correctly code various skin procedures. This article reviews the codes and guidelines for lesion removals discussed in Caperton’s presentation, “When Life Gives You Lemons: Skin It!” and explains how to avoid common mistakes when coding skin procedures. We’ll start with an overview of the skin and its layers, and then delve into damaged skin treatment services by means of tag removal, shaving, excision, and repair procedures. Because this is a large topic, we’ll break this discussion into a three-part series. This first article focuses on skin layers, tag removal, and shaving.
Peel Away the Layers
The skin is the body’s largest organ, covering a total surface area of approximately 20 square feet. This fast-growing organ functions in many roles, including serving as a protective layer against microorganisms, aiding in body temperature regulation, and enabling the sense of touch. Skin is comprised of two layers, each unique in its components and functions.
- Epidermis – The thin, outermost layer of the skin, the part you can see and touch, is called the epidermis. It provides a protective, waterproof barrier that also creates our skin tone. Skin color is created by special cells called melanocytes in the epidermis that make melanin, a naturally occurring pigment. Melanin not only gives skin its color, but it also protects us from the sun’s damaging rays. At the bottom of the epidermis, new skin cells are constantly forming. These cells slowly move toward the surface and are eventually shed off.
- Dermis – Beneath the epidermis lies the dermis. This layer contains blood vessels, nerves, sebaceous glands, sweat glands, and hair follicles, and is held together by connective tissue fibers. The dermis gives skin both strength and flexibility. Sweat helps to cool and detoxify the body, while oil moisturizes and creates a waterproof barrier. Nerve endings in the dermis provide information on how things feel when we touch them and send this information to the brain.
- Subcutaneous tissue – Subcutaneous tissue lies beneath the dermis, although it is not technically a part of the skin. Sometimes referred to as the subcutis or hypodermis, this tissue consists of a network of collagen and fat cells that provides a cushiony layer of insulation and attaches the dermis to underlying muscle and bone. Subcutaneous tissue helps keep the body warm, acts as a fuel reserve, and absorbs shocks to protect us from injury.
Damaged Skin and Potential Coding Pitfalls
Dermatology is the branch of medicine that studies the skin, hair, nails, and associated diseases. Dermatologists diagnose, manage, and treat dermatological conditions both medically and surgically. They commonly remove tissue samples of skin and subcutaneous tissue to establish a diagnosis, treat symptomatic lesions, or excise potential tumors. Coding and billing for the diagnosis and treatment of skin lesions are laden with potential pitfalls that could lead to delayed payments, denials, increased payer scrutiny, and more. We’ll examine skin procedure coding for lesion removal and how to avoid common coding mistakes.
Skin tag removals, shave removals, and excisions are just a few of the basic procedures routinely performed by dermatologists to obtain tissue samples. Consideration of removal type, depth, intent, and lesion location drive proper code selection. It’s imperative to understand these procedures and the codes surrounding their use to properly report lesion removals (11200-11646).
Skin Tag Removal (11200-11201)
Skin tags, or dermatofibromas, are fleshy benign growths that typically connect to the underlying skin by a thin stalk. These protruding pieces of skin usually occur where clothing rubs against the skin or where there is skin-to-skin friction, such as the neck, underarms, groin, and eyelids. Skin tag removal is done at the provider’s office; methods include cutting with scissors or a blade, ligature strangulation, electrocauterization, freezing with liquid nitrogen, or a combination of therapeutic modalities. Removal codes include a simple closure with or without local anesthesia.
Coding skin tag removal is based on the number of tags removed:
Removal of up to 15 lesions: 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions.
For additional lesions after the first 15: +11201 Each additional 10 lesions (or part thereof) (List separately in addition to code for primary procedure).
Removal of skin tags is often considered cosmetic. Therefore, payers may not reimburse you for these services. Check with your payer. Review the documentation and look for any mention of bleeding, itching, pain, or change in physical appearance to support medical necessity.
- Coding for shave removals and excisions requires the intent to remove the entire lesion.
- Unlike shave removals, excisions can be coded only if the lesion is removed to the level of the subcutaneous fat.
Shaving of Epidermal or Dermal Lesions (11300-11313)
Shaving effectively removes superficial epidermal and dermal lesions that are relatively small and uncomplicated. Use these codes when the entire lesion is removed for therapeutic purposes. It involves sharp removal by transverse incision or horizontal slicing, without full-thickness dermal excision, and does not require sutures. In other words, the physician places the scalpel horizontal to the patient’s skin and slices off the lesion.
Code selection is based on lesion location, then by diameter. Codes 11300-11313 include local anesthesia and chemical or electrocauterization of the wound. Keep in mind:
Append modifier 59 Distinct procedural service for each additional lesion when multiple lesions are shaved.
If an independent procedure is performed with the intent of obtaining tissue to send to pathology for a diagnosis, report it using biopsy codes (11100-11101).
If performing a shave biopsy, see 11102-11103.
Apply Your Knowledge
Now that we’ve reviewed lesion removal coding, let’s apply your knowledge to a case scenario.
Example: The dermatologist removes two elevated epidermal/dermal lesions from a patient via shaving. One lesion is located on the face and has a diameter of 0.7 cm. The second lesson is on the upper arm and has a diameter of 0.4 cm.
Local anesthesia is injected beneath the lesion. A scalpel blade is placed against the skin adjacent to the lesion and the physician uses a horizontal slicing motion to excise the lesion from its base. The wound does not require suturing and bleeding is controlled by electrical cauterization. This same procedure is repeated on the second lesion.
Coding: Report the facial lesion with 11311 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membranes; lesion diameter 0.6 to 1.0 cm.
Report the lesion on the upper arm using 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less. Append modifier 59 since the descriptor specifies a single lesion; one code will be reported for each lesion that the doctor removes by shave technique.
The codes reported are 11311 and 11300-59.
More to Come …
Stay tuned for more articles discussing lesion removal via excision and repairs.