Internal Medicine Coding Alert

Question: A new patient reports to the internist with lesions on his chest. During a level-three E/M service, the internist discovers and excises a 0.5 cm lesion from the patient's upper left chest, a 1.1 cm lesion from the lower left chest, and a 0.6 cm lesion from the center-left chest area. The pathology report was negative on all lesions. Should I add the repair lengths together or code these procedures separately?

Tennessee Subscriber

Answer: Code each lesion removal separately; remember to report the longest excision first, as it is the only one that does not face a pay reduction for multiple procedures. On the claim, report the following:

• 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) for the 1.1 cm excision,

• 11401 (... excised diameter 0.6 to 1.0 cm) for the 0.6 cm excision,

• 11400 (... excised diameter 0.5 cm or less) for the 0.5 cm lesion,

• modifier 51 (Multiple procedures) appended to 11400 and 11401 to show that the excisions were separate,

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M,

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the E/M and removals were separate services, and

• 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum) appended to 11402, 11401, 11400, and 99283 to represent the patient's lesions.