Focus on Details in Lesion Coding
Size, location, complexity all figure into your choices. Coding for lesion removal in the emergency department (ED) can be difficult at best. First, you must take into consideration the level of evaluation and management (E/M) that precedes the lesion removal; then, you’ll have to code for separate procedures when they occur during the lesion removal. Take this advice for coding your ED lesion removals and get it right the first time, every time. I.D. Lesion Type, Size Before Coding When lesion removals occur in the ED, they are often benign lesions and will fall into the code range of 11400 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less) through 11446 (Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm). When choosing among these codes, you must mind the lesion’s size, location, and if there was a simple and/or complex repair of the deficit. When lesion removals are performed, you must also consider National Correct Coding Initiative (NCCI) edits for laterality and modifiers required. There are a number of areas for consideration when assigning lesion removal codes. First and foremost is the lesion type and size. Another important aspect of lesion removal is the excision (including simple closure of the area), including the use of anesthesia. CPT® guidelines inform coders that code selection is based on the measurement of the greatest clinical diameter of the lesion plus the margin required for the complete excision (i.e., lesion diameter + most narrow margins required = total excised diameter). When multiple procedures are required to remove a lesion, we are guided to report only the code representing the method used to complete the procedure. When multiple lesions are removed, modifier 59 (Distinct procedural service) may be appended only in cases where lesions are removed from separate sites. When performed in the ED, you will also need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the ED E/M code to define the procedure from the E/M portion of the encounter. (Lesion removal encounters in the ED will always be preceded by an ED E/M service.) If the lesion was completely removed through the dermis (including margins), CPT® guidelines instruct you to assign codes from the 11400 category. You should be cautious of how coding changes based on the anatomic location of the lesion removal. If more than one lesion is removed and one of those lesions is larger than 0.5 cm, an intermediate or complex repair may be reported in addition to the lesion removal, when performed. Removal of a lesion that is less than 0.5 cm does not preclude also reporting an intermediate or complex repair for a larger lesion. NCCI edits also inform the coder that if the lesion removal, incision, or repair requires further debridement of non-viable tissue(s) surrounding the lesion, incision, or injury to complete the procedure, the debridement is not separately reportable. Tissue Transfers a Possibility NCCI guidelines also report that the CPT® code book classifies closures as simple, intermediate, or complex. If the closure cannot be executed by one of these listed procedures, adjacent tissue transfer or rearrangement may be reported. You’ll report these procedures with codes from 14000 (Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less) through 14350 (Filleted finger or toe flap, including preparation of recipient site). Adjacent tissue transfer includes excision of the lesion and repair of the wound. Therefore, separate reporting is not allowed when the tissue transfer is performed on the same lesion or injury. Do This When Documenting Lesion Removals Documentation of the procedure in its entirety is crucial to proper code selection and modifier usage. Physicians should be educated regarding clear and precise documentation, including the lesion’s size, location, and type — as well as the method utilized to remove the lesion — to support coding assignment. For the pre-removal ED E/M, the level of service should be based on the intervention(s) that were performed during the medical care required for presenting problem(s) and symptoms that resulted in the diagnosis of the patient. Then, you’ll choose the appropriate code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set for the E/M with modifier 25 appended. From there, you’ll be ready to choose the appropriate lesion removal code, or codes, for the encounter. Amy C. Pritchett, MSHA, AAPC Fellow, RAP, CRC, CPA-RA, CCS, CPC, CPMA, CPCO, CDEI, CDEO, CDEC, CANPC, CASCC, CMPM, AAPC Approved Instructor, Approved ICD-10-CM/PCS Trainer, Senior Manager, Risk Adjustment/Hospital/Coding Audit and Education at Pinnacle Enterprise Risk Consulting Services
