Dermatology Coding Alert

Published on Sat Dec 17, 2016 PDF

Always wait on pathology report before deciding on malignancy.

Dermatology coders looking to decipher lesion excision claims have to make some very important decisions in order to arrive at the proper code, or codes.

Expert breakdown: Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb., says there are a few focused questions that can help you pinpoint the proper lesion removal code.

Read on for expert input on these “Big 3” questions, and keep the advice in mind to avoid shaving deserved dollars from your practice’s lesion removal services.

Q: Was the lesion benign or malignant?

A: There are no providers at a dermatology practice that have the tools and knowledge to decide, with certainty, that a lesion is benign or malignant. Therefore, dermatology coders should always wait for the pathology report before choosing a removal code.

Once the pathology report returns, you should base your decision on these factors:

1. If the pathology report describes a benign lesion, or one of uncertain behavior (for example, indications of atypia or dysplasia), you must use a benign lesion excision CPT^® code.
2. To assign a malignant lesion excision CPT^® code, the pathology report must confirm a malignancy. This malignancy could 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).

Remember: “Be certain that your code selection is backed up by the pathology report, even if that means holding the claim for a few days,” recommends Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa.

Q: Where was the lesion located (anatomic site)?

A: CPT^® breaks lesion removal codes down by anatomic site. You’ll need to know which area of the body in order to choose from the following codes:

Trunk, arms or legs: 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) through 11406 (… excised diameter over 4.0 cm) for benign lesions; 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less) through 11606 (… excised diameter over 4.0 cm) for malignant lesions.

Scalp, neck, hands, feet, genitalia: 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) through 11426 (…  excised diameter over 4.0 cm) for benign lesions; 11620 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) through 11626 (… excised diameter over 4.0 cm) for malignant lesions

Face, ears, eyelids, nose, lips, mucous membrane: 11440 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) through 11446 (… excised diameter over 4.0 cm) for benign lesions; 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less) through 11646 (… excised diameter over 4.0 cm) for malignant lesions.

Before you begin to consider a lesion removal code, be sure to know the anatomical site of the procedure, for coding purposes.

Q: What was the excised diameter of the lesion?

A: Measurement of the lesion is another important aspect of correct lesion removal coding, confirms Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa.

According to 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.”

Translation: “Excised diameter equals the length of the lesion at its longest point, plus two times the narrowest margin,” explains Falbo. 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]), she continues.

Also: The physician should measure the lesion plus margin before the excision, Falbo says. “Do not select codes based on the size of the incision and/or the resulting surgical wound,” she warns.