Medicare Compliance & Reimbursement

Lesion-removal ignorance could be costing your practice money.

Myth: Medicare won't pay for shave removal codes (11300-11313) for benign lesions.

Reality: Medicare carriers will cover these codes, along with other lesion removal codes, says Inga Ellzey, president and CEO of the Inga Ellzey Practice Group in Casselberry, FL.

Many coders decide Medicare won't cover 11300-11313 because they've received denials, Ellzey notes. But any denials your practice receives will likely be due to improper documentation or incorrect diagnosis codes.

Coding: There are three different ways of removing a lesion, Ellzey explains. If your physician just removes part of the lesion, then you should bill biopsy codes 11100-11101. If the physician removes the lesion, but the removal is superficial and doesn't extend into the fat, you should bill the shave removal codes.

And if the physician removes the lesion, all the way down into the fat, then you should bill excision codes, depending on whether it was benign (11400-11471) or malignant (11600-11646).

The shave removal codes almost always pay more than the biopsy codes, so you could be losing money if you default to the biopsy codes, Ellzey warns.

Terminology: Beware of terms like "shave excision" or "shave biopsy." The physician performed either a biopsy, a shave removal or an excision, says Ellzey. If your physician's documentation includes terms that muddle the differences among those three things, you're asking for trouble in audits.

Another myth: Many coders believe that the physician's intent determines which code they select. If the physician wanted to obtain a specimen for biopsy, they argue, you should just use a biopsy code. But in fact, the method of removal should determine your code, not what was going through the doctor's head, says Ellzey.

Diagnosis codes: Pretty much every Medicare carrier has a version of "The Benign Skin Lesion Removal Policy," says Ellzey. These policies include three lists of ICD-9 diagnosis codes. The first list contains ICD-9 codes that will always convince your carrier to pay for the removal. The second list contains ICD-9 codes that will obtain reimbursement for lesion removal only if you include a secondary diagnosis from the third list.

Watch out: Most carriers will never pay for lesion removal if the physician documents only that the lesion is "irritated." The lesion must be inflamed, bleeding, painful, red or one of a few other things, Ellzey cautions.