ED Coding and Reimbursement Alert

Here's why you should never label a lesion malignant on your own.

Patients reporting to the ED for lesion removal present special challenges for the coder, who typically doesn't have time to wait on pathology reports before choosing a CPT code for the procedure.

Further, you have to know how CPT breaks the body down when a patient reports with an oozing scab or some other sort of lesion.

Follow our experts' advice with this FAQ on the challenges of lesion removal coding in the ED. Keep this advice close, and you'll have all the guidance you need whenever the physician removes a lesion.

1. Where do I start?

Coders need several pieces of information before they can choose a proper lesion excision code. Step one is finding out the anatomical area of the lesion. For coding purposes, CPT breaks lesion removals into the following categories, says Yvonne P. Mayer, CPC, senior coding analyst at Bill Dunbar and Associates LLC in Indianapolis:

• Trunk, arms or legs (11400-11406 for benign lesions, 11600-11606 for malignant lesions)
• Scalp, neck, hand, feet and genitalia (11420-11426 for benign lesions, 11620-11626 for malignant lesions)
• Face, ears, eyelids, nose, lips mucous membrane (11440- 11446 for benign lesions, 11640-11646 for malignant lesions).

Example: The ED physician performs an expanded problem focused history and expanded problem focused examination on a patient complaining of a lesion on her scalp. The physician uses a scalpel to remove a 3.2 cm benign lesion from the patient's scalp. Notes indicate low-complexity medical decision making.

On the claim, you'd report the following:

• 11424 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm) for the lesion removal
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ....) for the ED E/M service
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and the lesion removal were separate services.

2. How can I tell if the lesion is benign or malignant?

The coder should never have to make a call between a benign and malignant lesion. It is unethical and illegal to diagnose any patient with any condition without the burden of proof.

"The only way to be sure that a lesion is malignant is to wait for a path report; this is not a problem in a dermatologist's or plastic surgeon's office," says Sharon Richardson, RN, compliance officer with Emergency Groups' Office in Arcadia, Calif.

"But ED charts are usually sent for billing within a day or two, so you have to default to the benign [removal] codes, unless you have pathology confirmation that the lesion is malignant," Richardson explains.

Do this: Make sure the physician signs off on the pathology of the lesion, even if it is benign. "The physician needs to be the one to document the findings," reminds Pamela McKinley, RHIT, coder at Medical Accounts Services in Frederick, Md.

3. OK, how about measuring total removal size?

If you are reporting only the length of the lesion when choosing a removal code, you're selling the ED short.

"When determining the correct size of the excised lesion the provider should add together the [greatest clinical] diameter of the lesion plus the size of the margins [required]," explains Mayer, who offers this example:

Example: The ED physician excises a patient's back lesion; the wound has a diameter of 1.5 cm and the margins the physician needs to complete the procedure are 0.5 cm on the left and 0.5 cm on the right. Physician notes that tissue is most likely benign.

Coding: Add the excised lesion diameter (1.5 cm) to the margins (0.5 cm + 0.5 cm) to get a total of 2.5 cm. On the claim, you'd report 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm) for the lesion removal.

Also, make sure that "the measurement of the lesion plus margins is made prior to the excision. Do not report size from the pathology report," advises Cheryl Starner, CPC, revenue integrity analyst for Missouri's Truman Medical Centers headquartered in Kansas City.

Why? The specimen will shrink post-removal and you'll be under-coding for your physician's services if you wait on the pathology report to return.