General Surgery Coding Alert

See if you miss extra pay opportunities.

Do you know when your skin excision cases warrant a separate closure charge or maybe an additional code for lesion re-excision? If you don’t, you might be leaving your general surgeon’s money on the table. 

Test your knowledge of the 11640-11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips…) CPT® codes, then compare your answers with our experts’ below.

Up front tip: Remember that for skin lesion excisions, you should base your code selection on the excised diameter measured prior to excision using the following formula: widest lesion width + (narrowest margin x 2). The “diameter with margins” in the following examples are based on this formula. 

Scenario 1: Referral for Lesion Removal

A family physician refers a patient to your general surgeon for removal of a “mole” on the patient’s left cheek. The surgeon suspects that the mole is a small basal cell carcinoma (later confirmed by pathology) and therefore removes the lesion with adequate margins. The surgeon 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 would you code this scenario?

Scenario 2: Excision with Complex Repair

In the next case, a primary care physician refers a patient to the general surgeon for an excision and repair of a squamous cell carcinoma (diagnosed from an earlier biopsy) on the patient’s back. The surgeon excises a lesion that measures 3.2 cm with margins. 

Based on the size and location of the defect, the surgeon must use scissors to gently free the skin from the underlying muscle and deep tissue and perform layered closure of the wound created by the excision. How would you code this scenario?

Scenario 3: 1 Lesion, Multiple Excisions

The surgeon excises a suspected cancerous neck lesion in the office. The pathology report returns at a later date showing a diagnosis of melanoma with positive margins — meaning that the surgeon did not remove all the malignancy and must excise additional tissue. 

The surgeon schedules an additional procedure in the operating room to excise wider margins. This time the pathology report confirms melanoma, but declares margins clear. How should you code the initial excision and the follow-up re-excision?

Read On for These Expert Answers

Once you’ve tried your hand at the three cases, check our answers to see if you would have missed payment for any procedures if these scenarios had played out in your general surgery practice. 

Solution 1: Referral for Lesion Removal

In this case, you should report the excision alone (11641, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm).

Because the referral was for specific removal, there is no billable E/M service, especially if the surgeon can identify the lesion by simple exam.

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.

Opportunity: Suspecting basal cell carcinoma, your surgeon might have decided to perform a further exam for other suspicious lesions and taken a comprehensive history. If you had documentation to that effect, you could possibly bill for a new patient visit, according to Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Tex. Even if your surgeon has seen the patient before, you can use a new-patient code if you include a statement that the previous visit was for an unrelated issue.

Solution 2: Excision with Complex Repair

First, you should code the excision as 11604 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm).

Remember: The malignant lesion excision codes include only simple closure. You can additionally report intermediate or complex closure, or defect reconstruction, when performed. 

In this case, the surgeon documented a complex closure, which included undermining tissue and suturing the defect in layers. That means you should report 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) in addition to 11604 for the surgeon’s work. 

Solution 3: 1 Lesion, Multiple Excisions

How to code: Report the initial excision based on size and site (for example, 11621, Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm), as well as any allowable wound repair that the surgeon provides in his office.

For the additional excision on a later day in the OR, report another excision code as appropriate to the size of the tissue removed, such as an additional 11621 for a re-excision of a neck lesion between 0.6 and 1.0 cm. Again, separately report any allowable wound repair beyond a simple repair.

If the re-excision occurred during the initial procedure’s (11621) global period, that is, within 10 days of the initial procedure, you must append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the lesion excision code.

The surgeon will attempt to excise all malignant tissue on the first try, but if he doesn’t, he’ll have to go back as many times as necessary to ensure he has provided adequate margins.

Diagnosis tip: If the surgeon excises a malignant lesion and must re-excise the same lesion to ensure adequate margins, you should use the same diagnosis for the re-excision as you did for the initial excision, even if the pathology report for the re-excision returns negative for malignancy, according to AMA recommendations.