General Surgery Coding Alert

CPT 2010's overwhelming number of new and revised soft tissue tumor and resection codes will make choosing the proper code a challenge. We're here to help.

You learned four tips for selecting the proper new or revised CPT 2010 soft tissue tumor code in last month's article, "Make Sure Your Tumor Excisions 'Measure Up' Starting Jan. 1."

Now you can supercharge that knowledge with the following tools:

Since code selection partly depends on the soft tissue tumor's size, how will you get that information? "Just measure it," advised John P. Heiner, MD, professor at University of Wisconsin Hospital and Clinics in Madison at the CPT and RBRVS 2010 Annual Symposium in Chicago. You should measure the longest dimension of an oblong mass, according to Heiner.

The CPT manual gives specific directions for measuring a soft tissue mass excision or resection as follows:

1. Measure the "greatest diameter of the tumor,"according to CPT.

2. Add the "most narrow margin" required for complete tumor excision.

3. Make the measurement at the time of excision.

Don't let $ shrink with tissue: Because tissue shrinks during processing, waiting to use the excision measurement from the pathology report instead of the time of surgery could mean reporting 23076 (Excision, tumor, soft tissue of shoulder area, subfascial [e.g., intramuscular]; less than 5 cm) instead of 23073 (... 5 cm or greater). That would cost you $136.10 (based on the Medicare physician fee schedule national amount for 23076 and 23073 using conversion factor 36.0846).

When you face a new soft tissue tumor excision/ resection, you can use a series of questions to lead you to the proper code. Think of this tool as a "decision tree" that keeps leading you to the proper branch.

Example: See how answering each of these four questions, in order, narrows your code choices until you arrive at the proper code. For this example, assume the surgeon excises a subcutaneous lipoma of the back that is 2.5 cm (including the smallest margin needed for complete excision) and requires simple closure.

1. What is the body site? -- back -- 21930-21936

2. Is the tumor malignant (or equal work)? -- no -- 21930-21933 (if yes, skip to question 4 to determine size class)

3. Is the tumor subcutaneous or subfascial? --subcutaneous -- 21930-21931

4. Is tumor excision 3 cm or greater, or less than 3 cm? -- less than 3 cm (2.5 cm) -- 21930 (Excision, tumor,soft tissue of back or flank, subcutaneous; less than 3 cm)

New way to account for depth: Notice that Step 3 allows you to distinguish soft tissue tumors based on depth. "Until these codes, there has never been a way to express the depth of removing a tumor or tumorous mass except with modifier 22 (Increased procedural services)," says Leslie Johnson, CPC, quality control auditor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net. Using modifier 22 means much greater difficulty in getting payment that is reflective of the physician's work, so these specific codes should be a boon for general surgeons.

Do this for both zones: "According to direction given at the CPT and RBRVS 2010 Annual Symposium, if a tumor starts in the subcutaneous tissue and extends into the subfascial area, you should use the subfascial code," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Don't miss closure distinction: All of the new and revised soft tissue tumor excision and resection codes include the surgeon's work for simple or intermediate repair. If the defect created by the excision requires complex repair, you should separately report that service using the appropriate code from the range 13100-13153.

Table 1 places all the new CPT 2010 soft tissue tumor excision and resection codes in a matrix to make code selection easier. Follow these steps to use the table:

1. Find the body site in column 1, as well as the excision/resection distinction.

2. For excisions, note the appropriate depth class (subcutaneous or subfascial) in column 2.

3. Follow the depth distinction to column 3 to see the two code choices.

4. Follow the two codes to column 4 to see the size cutoff -- with the first code in the pair being smaller than the cutoff and the second code in the pair being greater than or equal to the cutoff.

Notice variation: Although most of the code groups for a particular body site list the codes in numerical order, from subcutaneous excision to subfascial excision to resection, that's not always the case. Study the following exceptions so you don't let expectations trip you up when you're using these codes:

1. For soft tissue tumor excisions of the abdominal wall (22900-22903), CPT lists subfascial codes before subcutaneous codes.

2. For soft tissue tumor of leg or ankle, CPT lists the radical resection codes before the excision codes.

3. CPT lists quite a few codes out of numerical sequence -- the # symbol identifies those codes.