ED Coding and Reimbursement Alert

Pathology procedures will shrink lesion and your ED's reimbursement

When patients with lesions report to your ED for treatment, you-ll need to answer several questions to submit a spot-on claim.

To properly report lesion removals, coders need to know the lesion type, the body area, and the exact measurement of the excised area. Getting just one of these wrong can result in a miscoded claim, and a denial.

Follow this expert advice to choosing the proper lesion excision code for each encounter.


Determine Lesion Type First

On your lesion excision claims, you should know whether the physician removed a benign or malignant lesion from the patient, says Sean Weiss, CPC, CMPE, founder of the Complete Medical Consulting (CMC) Group in Atlanta. When reporting lesion repair, choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions, he says.

Benign or malignant? There is no way for the coder to know whether the excised lesion was benign or malignant on her own, but she cannot choose the appropriate excision code without a benign or malignant diagnosis. ED physicians rarely treat malignant lesions, so some ED coders will report the lesion as benign without confirmation, according to Sharon Richardson, RN, compliance officer with Emergency Groups- Office in Arcadia, Calif.

However, if you want to know the lesion type before coding the excision, you should wait on the pathology report, Richardson says.

That way, you-ll know for sure whether your physician treated a benign or malignant lesion, and your diagnosis coding will be more exact.


For Coding, CPT Breaks Body into 3 Areas

Once you confirm whether the lesion is benign or malignant, you should narrow your code choice further based on which area of the body the physician operated on. For coding purposes, CPT breaks lesion removal codes into three body areas:

- trunk, arms, legs (11400-11406, 11600-11606)

- scalp, neck, hands, feet, genitalia (11420-11426, 11620-11626)

- face, ears, eyelids, nose, lips, mucous membrane (11440-11446, 11640-11646).

So if the ED physician removes a malignant lesion from a patient's left leg, youchoose the appropriate lesion excision code from the 11600-11606 code set.

Exception: If the ED physician is treating a patient for hidradenitis (705.83), you will not choose from the above codes, Richardson says. On hidradenitis repairs, you would choose the appropriate code from the 11450-11471 code set.

Include Margins on Lesion Measurements

Once you have discovered the lesion type and location, you-re ready to record the lesion's exact measurement for reporting purposes. When calculating lesion size, don't just measure the lesion: be sure to report the total excised diameter on the claim, Weiss says.

To determine the appropriate lesion excision size, measure the lesion's widest diameter point, then add double the width of the narrowest margin.

According to CPT, -Code selection is determined by measuring the greatest [...]