General Surgery Coding Alert

Append modifier 58 for OR re-excisions during global period

Coding all services involved in a lesion removal can quickly lead you into -gray- areas, such as determining if you should report a separate E/M service when performing minor excisions in the office.

Use these three case studies to understand how you should handle confusing lesion coding scenarios. Case Study 1: Referral With Simple Excision A family physician (FP) refers a patient to your general surgeon for excision of a -mole- on the patient's upper left arm. The surgeon suspects that the mole is a small basal cell carcinoma. She performs an excision to remove the lesion, which measures 0.9 cm with margins, in the office. She then closes the wound via simple repair and releases the patient.

How to code: In this case, you would probably report the excision alone (11601, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.6-1.0 cm).

-Because the referral was for specific removal, I understand there is no billable E/M service, especially if the surgeon can identify the lesion by simple exam,- says South Carolina general surgeon M. Trayser Dunaway, MD, FACS.
 
The bottom line: All procedures include a -minimal- E/M, so unless the surgeon can provide documentation for a significant, separately identifiable E/M service above and beyond that usually included in the excision, you are limited to reporting the excision only.

Learn more: Look to next month's General Surgery Coding Alert for more information on reporting a separate E/M with a same-day procedure or service.
 
Case Study 2: Referral With Unexpected Findings
 
In the next instance, the FP refers the patient to the surgeon for a skin lesion removal. This time, however, the surgeon views the lesion as potentially more serious and not diagnosable by simple exam. The surgeon performs a thorough exam and punch biopsy to determine the nature of the lesion. The biopsy returns positive for malignancy, and the surgeon schedules the patient for excision at a later date in the operating room (OR).

How to code: First, you should report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

In this case, if the surgeon documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...). -This was not a simple evaluation,- Dunaway says. -The surgeon had to spend considerable time with the patient.-

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to distinguish the E/M service as significantly above that included with the biopsy, says [...]