Otolaryngology Coding Alert

There's a simple trick to reporting re-excisions during the global period

Coding all services involved in a lesion removal can quickly lead you into -gray- areas, such as determining whether you should report a separate E/M service when performing minor excisions in the office.

Use these three case studies to understand how you should handle confusing lesion coding scenarios. Case Study 1: Referral With Simple Excision A family physician (FP) refers a patient to your ENT for excision of a -mole- on the patient's left check. The ENT suspects that the mole is a small basal cell carcinoma (which is later confirmed by pathology). She 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 to code: In this case, you would probably 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, I understand there is no billable E/M service, especially if the ENT can identify the lesion by simple exam,- says South Carolina surgeon and educator M. Trayser Dunaway, MD, FACS.

The bottom line: All procedures include a minimal E/M, so unless the ENT 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.

Learn more: For more information on reporting a separate E/M with a same-day procedure or service, see -3 Tips Minimize Modifier 25 Mishaps,- on page 12 of the February 2006 Otolaryngology Coding Alert. Case Study 2: Referral With Unexpected Findings In the next instance, the FP refers the patient to the ENT for a skin lesion removal. This time, however, the ENT views the lesion as potentially more serious and not diagnosable by simple exam. The ENT performs a thorough exam and biopsy to determine the nature of the lesion. The biopsy returns positive for malignancy, and the ENT schedules the patient for excision at a later date in the operating room (OR).

How to code: First, you should report the biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

In this case, if the ENT documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...). -This was not a simple evaluation,- Dunaway says. -The ENT had to spend considerable time with the patient.-

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other [...]