Dermatology Coding Alert

Published on Wed Oct 05, 2005 PDF

Hint:  Coding depends on how much of a lesion the dermatologist removes

When a dermatologist removes a lesion and sends it to pathology, do you code it as a biopsy or an excision? The answer isn't always straightforward, but it can make a huge difference in the reimbursement your office can fairly claim.

Whereas a single biopsy can bring in about $80 (based on 2.10 RVUs in the 2005 Physician Fee Schedule, unadjusted for geographic area), a lesion excision can reimburse as much as $465 (12.29 RVUs for 11646, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm). Use this coding quiz to make sure you're not losing your practice money unnecessarily. The truth shall set you free--from losing over $300 each procedure.

Question #1: True or false: Report 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) whenever the physician sends a pathology.

Answer: False. It depends on whether the dermatologist removes just a portion of a lesion, or the whole thing. If the dermatologist removes the entire lesion, you may be able to report an excision code (11400-11646), says Paula Zilifian, CPC, coder for Robert M. Miller, MD, a dermatologist practicing in West Hills, Calif.

Documentation: Beware of ambiguous terms such as "excisional biopsy"--for CPT coding, a procedure is either an excision or a biopsy. CPT defines excision as "full thickness removal of the lesion, including margins." An excision requires removing the entire lesion to the subcutaneous level. If the documentation specifies that the removal was full thickness, subcutaneous or through the dermis, you should report an excision.

If the operative notes don't mention the excision's depth, you should look at the intent of the procedure. If the dermatologist intended to remove the entire lesion, code an excision. If, however, the only intent was to get a biopsy sample to obtain a diagnosis, code a biopsy.

Question #2: True or false: When performing two biopsies on the same site, report 11101 for the second and append modifier 59 (Distinct procedural service) to it.

Answer: False. This is another area where coders confuse the biopsy codes with the shaving or excision codes. If the dermatologist shaves or excises several lesions at once, you would need to append modifier 59 to each code after the first one you list, in order to show that each procedure was distinct and necessary. But code +11101 (... each separate/additional lesion [list separately in addition to code for primary procedure]) is exempt from modifiers, says Lori Lemond, CPC, PMCCI, coding supervisor for the Arizona Medical Clinic in Sun City, a multispecialty office with three dermatologists.

"By definition, it's a second lesion," she says, because it is an add-on code, which CPT specifies "must be used in conjunction with 11100." You do not need to append modifier 59 in order to report 11101 along with 11100.

However, if you are reporting a site-specific biopsy code more than once, you would append modifier 59.

Example: The dermatologist biopsies two lesions on a patient's lip. You would report:

• Line 1: 40490 (Biopsy of lip)

• Line 2: 40490-59.

Note: You may also be able to code this example as 40490 x 2. Be sure to check with your FI or payer to determine their requirements.

For more information on site-specific biopsy codes, see "Note 'Site' Specifics to Avoid Common Biopsy Pitfalls" in the May 2005 Dermatology Coding Alert.

Question #3: True or false: When a dermatologist follows a biopsy by removing the entire lesion, code for both the biopsy and the lesion.

Answer: False. The biopsy is included in the excision, per CPT and NCCI rules, Zilifian says. The CPT instructions before 11100-11101 read: "The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported."

Also note that the National Correct Coding Initiative includes 11100 as an intrinsic part of all of the shaving (11300-11313) and excision (11400-11646) codes, preventing you from reporting a biopsy along with those codes.

Exception: If the dermatologist biopsies a lesion but completely excises a different lesion, you may report both the biopsy and lesion codes.

Example: The dermatologist performs a biopsy of a lesion on a patient's arm and excises a benign lesion on the neck during the same visit.
 
You would report 11100 and 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) and append modifier 59 to the biopsy code.