General Surgery Coding Alert

Stick with what you know about lesion excision coding, experts say.

If the recent National Government Services (NGS) information about lesion excision coding has your practice up in arms, youre not alone. Coders have been asking questions and raising red flags about the recent local coverage determination (LCD). But dont fret: NGS plans to rescind the LCD advice about lesion excisions,experts say.

Decipher the NGS LCD

The portion of the NGS LCD that has led to controversy is in the general information section toward the bottom of the LCD. That section reads:

While it is recognized that some diagnoses resulting from an excision will at times be malignant, the diagnosis at the time the procedure was performed would most likely be 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin), and this would be the appropriate code, since proper coding requires the highest level of diagnosis known at the time the procedure was performed. Medical records maintained by the physician must clearly document the medical necessity for the lesion removal(s) if Medicare is billed for the service. & The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

It seems that NGS wants us to select an unspecified code even when we have a path report with a final diagnosis in hand, wrote Sheri Poe Bernard, CPC, CPC-H,CPC-P, vice president of clinical coding content for the AAPC in Salt Lake City in a letter to NGSs provider outreach department.

The issue: This advice goes against 2009 ICD-9 coding guidelines, which state: For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

The proposed LCD went against one of the core ICD-9 coding principles -- to code to the most specific information available, Bernard says. The idea that since the physician did not know the kind of lesion at the time the lesion was removed for biopsy means an unspecified code should be reported makes no sense. Code what you know. Thats always been the rule.

The wording of the LCD pretty much excludes any use of the malignant excision codes, as they are stating that an unspecified neoplasm diagnosis code should be used, which we cant use with a malignant excision code, says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio. And then that last statement about the pathologic interpretation being independent of the decision to remove the lesion also closes the door on holding the charges until the path comes back. Its a very, very sneaky way of basically excluding nearly all malignant excision codes. The only way I can see to use the malignant excision codes would be for a re-excision of a known malignancy.

NGS Officials Promise a Correction

Good news: NGS is planning to print an article soon that will clarify this issue, says George N. Costantino,MD, FACS, medical director for National Government Services in Syracuse, N.Y. According to Costantino, that article will read: Due to inconsistent and differing interpretations of coding instructions regarding this issue, the paragraphs pertaining to coding for excision of benign vs.malignant skin lesions are being removed from the SIA attached to the LCD for removal of benign skin lesions (L27362/A47397.) Providers are encouraged to code according to the coding instructions applicable to their various practice situations. NGS will not make an effort to make this coding more uniform and consistent at this time.

Warning: Bernard says that she has not yet seen any sort of retraction in print from NGS. So keep an eye out for forthcoming notice directly from NGS. However, on the CMS Web site superceded is written in red across the lesion excision LCD (www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=27362&lcd_version=13&show=all).

Stick With Previous Coding Guidelines

Bottom line: Despite the confusion generated by the NGS LCD, you should follow ICD guidelines and wait for the pathology report to determine if the lesion was benign or malignant when choosing a code for a lesion excision, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

Once you have the pathology report, youll choose from 11400-11471 for benign lesions and 11600-11646 for malignant lesions. Narrow your code choice further based on the body area the surgeon operated on, Cobuzzi explains. For coding purposes, CPT breaks lesion removal codes into three body areas. See the chart on the previous page for details on the code breakdown.

If your surgeon believed the lesion was suspicious, but it turned out to be benign, code the benign lesion, Bernard says.

Dont miss: One scenario might trip up your coding, however. Your surgeon performed a benign lesion removal, without taking wide margins -- in other words,the surgeon thinks the lesion is suspicious, but expects it to be benign -- but the pathology comes back as a malignant lesion. The surgeon will then have to go back and perform an additional excision, likely within the global period of the first procedure. You will report the first procedure using a code from the 114xx section, using the malignant diagnosis, Cobuzzi says. You will then report the second procedure using a code from the 116xx section, also using the malignant diagnosis.

Tip: I do believe that V71.1 (Observation for suspected malignant neoplasm) is a useful way to provide information to payers on the reason for the removal,Bernard advises. Physicians should work with individual payers to establish policies that allow for payment when a malignancy is suspected but not found.

NGSs view: The provider should follow the instructions applicable to their practice situation. However, the provider must be consistent in the method chosen,Costantino says. In other words, if he chooses to select the CPT code based on pathology report, he must do this in all cases, he explains.