General Surgery Coding Alert

Timing is everything for coding accuracy.

Waiting for the pathologist to measure an excised lesion could cost your surgeon plenty. But not waiting for the pathology report could saddle the patient with a misdiagnosis. Use these tips to ensure correct diagnosis -- and maximize pay.

Rule # 1 -- Measure First

You should select the appropriate lesion excision size code based on the surgeon's report. "If the surgeon doesn't measure the lesion before he cuts it out, he's cutting his reimbursement in half," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

Once the specimen is in the jar, the specimen shrinks down to half its original size, Bishop says. If the surgeon doesn't put the original size in the note, the coder has to code based on the smaller excision size listed in the pathology report. "That will cost the practice a lot of money," he points out.

CPT's excision sizes, including margins, are based on the surgeon's measurements. "Train providers to measure an excision and document it with a statement, such as 'I'm going to excise this X cm length by X width lesion. I took 4 cm margins,'" Bishop says. Explain to your surgeon the financial impact of including these details.

Add it up: You should determine the lesion size for coding purposes based on the largest lesion diameter plus two times the narrowest margin. Remember, margins are on all sides of the lesion, so you'll double the smallest margin measurement. For instance, taking a 4 cm margin on all sides of the lesion equals a total of 8 reportable cm in addition to the diameter of the lesion itself. "Don't let your physicians cut themselves short," Bishop encourages.

Hold Diagnosis for Path Report

You should always choose the malignant or benign excision code based on the results of the pathology report, even if the surgeon does not have that information at the time of surgery. The pathology report offers the definitive diagnosis that serves as the basis for the CPT excision code selection.

A surgeon might visually identify a lesion as benign or malignant, but you still want to code the excision based on the pathology report. For malpractice reasons, the physician has to protect himself in the event a benign-appearing lesion really ends up being malignant, Bishop says. On the flip side, you don't want to mislabel the patient. The diagnosis could cause the patient's insurer to drop coverage.

Proper protocol: "We always choose the excision code after the pathology report returns," says Robyn Markussen, in the coding department of Family Practice Associates PC in Kearney, Neb. "If the pathology shows malignancy, we code the procedure as excision of a malignant lesion."

Downplay concerns that patience could cause payment losses. "Sitting and waiting for three to four days for the path report does not change cash flow," assures Bishop.

Check Anatomic Location

After receiving the pathology report, review the documentation for excision size and location. "Then it's all about location from the anatomical site to make sure the practice is getting all revenue," Bishop notes.

Each anatomical group contains lesion excision sizes ranging from small to large lesions. CPT groups lesion excision codes into three anatomical groups shown in the table.

Example: Documentation reads, "Excised face lesion 1.0 cm length by 2.0 cm width lesion, taking 0.2 cm margins." The pathology report comes back benign, and you mark 11443 (Excision, benign lesion including margins, except skin tag [unless listed else-where], face, ears, eyelids, nose, mucous membrane; excised diameter 2.1 to 3.0 cm) for the 2.4 cm codeable size ([2.0 lesion diameter] + [0.2 x 2 margins]). If, however, the surgeon had failed to document the size and the pathology report measured a 1.0 cm lesion plus 0.1 margins, you could code only 11442 (... excised diameter 1.1 to 2.0 cm), resulting in a loss of $35 (Code 11443 pays $207.59, while 11442 pays $172.93 for non-facility national amount using 36.8729 conversion factor).

Forgetting to give the surgeon credit for the margins would reduce the code to 11441 (... excised diameter 0.6 to 1.0 cm). This would cost the practice approximately $54 (Code 11441 pays $153.76 for non-facility national amount using 36.8729 conversion factor).