ED Coding and Reimbursement Alert

If a patient reports to the ED requiring lesion removal, you’ll need to get ready to do some measuring.

Why? Lesion removal coding is all about the numbers; specifically, the numbers regarding total treatment area. If you’re off on these calculations, your coding could be off, too — which could lead to negative outcomes.

Check out this primer on the basics of lesion removal coding, and get your coding correct right down to the centimeter … seriously.

No Op Report? Use Benign Removal Codes

First, the basics of coding lesion removals.

For benign lesion excision, you’ll choose a code from the 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) code set. If the lesion is malignant, you’ll choose a code from 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less) through 11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm).

“These codes refer specifically to excision of lesions and does not include removal of skin tags, paring of calluses, shaving of lesions, or removal by other means than excision,” clarifies Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting. CPT^® defines excision as full thickness (through the dermis) removal including margins and includes simple (non-layered) closure when performed.

The rub: You cannot code for a malignant lesion removal without confirmation from pathology. So, if it’s possible, you should wait on a pathology report before choosing a benign or malignant lesion removal code. “The physician is often unsure as to the nature of the lesion. It would be irresponsible to tag a patient with a malignant diagnosis, for instance, when the lesion may in fact be benign,” says Martien.

If you cannot wait on pathology, you should report a benign lesion excision code.

Consider Margins When Measuring Lesion Size

When you’re choosing a lesion removal code, you’re going to need exact measurements for the lesion treatment area to choose the most accurate procedure code.

“When coding the removal of the lesion, CPT^® instructs us to include the margin excised as well. Margins (healthy tissue) are included for comparison with unhealthy tissue,” says Martien. “These dimensions should be taken from the physician note and not a pathology report. The reason for this is the storage fluid shrinks the tissue, which would result in an inaccurate measurement.”

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion plus the most narrow margins required equals the excised diameter).

CPT^® includes diagrams demonstrating how to measure the excised diameter as well as the margins of benign and malignant lesions.

Example:

A 22-year-old presents with painful sunburn while on a beach vacation. Upon examination the emergency physician also notices a lesion on her left shoulder, which measures 1.0 by 2.0 cm. The patient elects to have that removed while they are there. The emergency physician determines that margins of .02 cm are required for complete excision. Adding the excised diameter plus margins on either side yields 2.0 cm + .04 cm, totaling 2.4 cm. The patient did not want to wait for the pathology report, so it was coded as a benign lesion. Notes indicate a level-three ED evaluation and management (E/M) service preceded the lesion excision.

On the claim you would 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 back lesion excision) for the excision
• 99283(… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity.) for the E/M service for the sunburn and lesion evaluation
• 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) appended to 99283 to show that a significant, separately identifiable E/M preceded the lesion removal
• M75.92 (Shoulder lesion unspecified, left shoulder) appended to 11403 and 99283 to represent the patient’s lesion

Do This for Multiple Lesions in Same Area

When patients have multiple lesions removed in different body areas, coding is easy enough. You’ll report a code for each lesion removal with modifier 51 (Multiple procedures) appended to each code beyond the first.

Example: Encounter notes indicate that the provider excised a 1.1 cm lesion from the patient’s left arm. They also excised a 2.2 cm lesion from the patient’s left hand. Both samples were reported benign by pathology.

Since these occurred in different anatomical areas, you’d report 11423 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm) for the hand lesion excision. Then, you’d report 11402 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm) for the arm lesion excision with modifier 51 appended to show that the arm lesion excision was separate from the hand lesion excision.

However …: When coding for multiple lesion removals of the same pathology in the same anatomic area, the game changes.

“When multiple lesions are removed from the same body area, the size of each lesion is added together and only one CPT^® code is selected, based on the total of the lesions,” explains Martien.

“For instance, if the physician removes two lesions, which are determined to be benign, from the chest and upper arm, each measuring 1.0 cm and each with margins measuring 1.0 cm (for a total of 4 cm), you would choose CPT^® code 11404 [Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm].”