Dermatology Coding Alert

Published on Sat Dec 17, 2016 PDF

You might be able to report a separate E/M in some instances.

Check out these case studies in which the physician performs lesion removal services for a patient:

Case study 1: From Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

The case: A patient presents with compliant of a small lesion on their left arm that she is concerned about. The dermatologist removes the one lesion from the left arm, with total excised diameters of 0.5 cm. Pathology report confirms that the tissue is benign.

The coding: On this claim, report 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) with D23.60 (Other benign neoplasm of skin of unspecified upper limb, including shoulder) appended to represent the patient’s lesion.

Case study 2: From Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa.

The case: The dermatologist removes a single lesion from the patient’s left cheek. The lesion measures 1.5 cm at its widest, around which the dermatologist removes a margin of 0.5 cm. The pathology report reveals a neoplasm of “uncertain behavior.”

The coding: On this claim, report 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) with D23.30 (Other benign neoplasm of skin of unspecified part of face) appended to represent the patient’s lesion.