Ophthalmology and Optometry Coding Alert

Documentation of the removal method is essential to picking the right code.

When your ophthalmologist removes lesions from a patient's eyelids, you're faced with a coding dilemma that you can solve only by examining the physician's notes. You need to decide if the procedure is an integumentary procedure or an eyelid surgery procedure.

The answer determines whether you should flip to codes 11440-11446 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane ...) in your CPT® manual or if you should instead look at 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure).

Your code selection depends on the number, location, type and size of the lesions. Follow these expert tips to help make the right choice every time.

Watch for Margin Details

First step: Dig into your ophthalmologist's procedure documentation to determine which code set you should report.

The simple rule: If the excision involves mainly skin,use 11440-11446.

To report 67840, make sure the surgery involves more than the eyelid's skin. For example, the procedure might involve lid margin, tarsus and/or palpebral conjunctiva. These terms need to be indicated in the chart notes when documenting the removal of the lesion.

Tip: Select the appropriate lesion excision size code based on the ophthalmologist's report. "If the physician 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.

Example: Your ophthalmologist removes a single lesion from a patient's upper-left eyelid. The excision measures 0.8 cm in diameter and includes the lid margin, which the physician submits for pathologic examination. The pathology report returns a benign neoplasm finding.

You should report 67840 in this case because it is the most appropriate code to accurately describe your ophthalmologist's work. Code 67840's 7.8 relative value units will bring $265.02 into the office, over $100 more than 11441 (4.77 RVUs x 33.9764 conversion factor = $162.07). The pricing for 67840 takes into account the difficulty of working around the eye compared to other body parts.

Keep in mind: Selecting the most appropriate CPT® code to describe the physician's work is the driving factor behind your code assignment determination. So you should never base your code selection on reimbursement value.

Malignant vs. Benign Matters, Too

Second step: When your ophthalmologist performs an eyelid lesion excision that involves mainly the eyelid skin, you know you should turn to the integumentary lesion excision codes. The next question is which code in this section you should choose.

Key: For benign lesions, look at 11440-11446, and for malignant lesions turn to 11640-11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips ...). Because a lesion's nature can be very misleading based only on visual examination, you should always wait for the pathology report before billing the excision. Then select your code based on pathologic findings (benign or malignant) and the lesion(s) size.

Note: You should not use lesion excision and/or repair codes for skin tags. There are separate codes for skin tag removal (11200-11201).

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.

Watch for Multiple-Lesion Pitfalls

Ophthalmologists won't always excise just one lesion at a time, so you'll face another coding challenge when your physician removes multiple lesions. Because 67840 is an excision code, which means you report it by the lid, you can't report it with units -- unlike the integumentary codes.

How it works: If you're reporting 67840 for multiple lesions that are each on different lids, you can report 67840 more than once. If you're reporting a 11440-11446 code for multiple lesions on either the same or different eyelids, you should report the code multiple times.

Rule 1: Check with your payers to find out which modifiers they require when billing multiple lesion excisions. You will likely need to use either modifier 51 (Multiple procedures) or the eyelid modifiers (E1 for upper left, E2 for lower left, E3 for upper right, and E4 for lower right). Some payers will even want both 51 and the eye modifiers.

Rule 2: You cannot add up the lesions to arrive at a larger size. For example, if your ophthalmologist removes two lesions, both under 0.5 cm in diameter, you cannot code 11441 simply by adding the sizes together. Instead, you should report the procedures on separate lines using 11440 twice with the appropriate modifiers.