Otolaryngology Coding Alert

Coding for excision of additional margins is possible, but a good explanation is required.

Without spot-on knowledge of neoplasm coding, you could confuse payers by selecting the wrong code and see deserved reimbursement go up in smoke. Below is a cheek neoplasm case to sharpen your diagnosis and procedure coding skills. Review the op note, decide how to code it, and then match your responses to our coding experts'.

Examine Multiple Lesions, Graft Reconstruction

Pre- and post-operative diagnoses: (1) Verruciform leukoplakia with moderate dysplasia of the left buccal mucosa, R/O (rule out) SCCA (squamous cell carcinoma) and (2) leukoplakia of the  right buccal mucosa.

Indication: The patient is a 68-year-old male with a seven-month history of a left buccal lesion that was biopsied and confirmed as moderate dysplasia, which could not rule out well-differentiated SCCA. The lesion appears within a patch of verruciformappearing leukoplakia. Additionally, he has an area of benignappearing leukoplakia on the right gingivobuccal sulcus.

Procedures: After the patient was anesthetized and prepped, the surgeon delineated a margin of buccal mucosa centered over the dysplastic-appearing verruciform leukoplakia of the left buccal mucosa and then incised the mucosa down to the level of the buccinator muscle along the delineated margins. The surgeon removed and labeled the specimen, a single short stitch at twelve o'clock and a single long stitch at three o'clock.

The surgeon then noted that an area of heaped-up keratinized mucosa remained at the superior border of the defect; thus, the surgeon excised and labeled an additional 3 mm superior margin, a short stitch posterior.

Next, the surgeon noted an area of benign-appearing leukoplakia along the gingivobuccal sulcus of the right buccal mucosa. He performed an incisional biopsy 3 mm by 3 mm wide to send to pathology and closed the site.

Then, the surgeon harvested the dermal graft, using a Zimmer dermatome (set at 0.12-inch thickness) to elevate an inferiorlybased split-thickness skin graft. Next, he harvested a 5.5 by 4.5 cm dermal graft over the same site and laid the split-thickness skin graft down over the dermal graft harvest site and tacked it back to the skin.

Next, the surgeon tailored the dermal graft to fit the size of the left buccal mucosal defect, tacked stitches along the periphery to inset the dermal graft, and then applied central tacking before securing a bolster in place. Finally, the surgeon placed a Dobhoff tube in the left nasal cavity, sutured it to the septum, and used a Dedo laryngoscope to confirm postcricoid placement.

1: Look to Pathology for Diagnosis Codes

You may think of two cancer-related diagnoses for this case, namely 145.9 (Malignant neoplasm of mouth, unspecified, [buccal cavity NOS]) to represent the excision site and 145.0 (Malignant neoplasm of cheek mucosa [buccal mucosa]) to represent the biopsy site. You'd be right if the pathology had come back malignant for the two sites. Unless pathology is available, avoid using the cancer codes, advises Joanne Schade-Boyce, RDH, MS, CPC, ACS, PCS, owner of FairCode Associates in Towson, Md. The pre- and post-operative diagnoses state "R/O (rule out) squamous cell carcinoma."

The best ICD-9 codes to choose without a confirmed pathology report, says Barbara J. Cobuzzi, MBA, CPC, CPCH, CPCP, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions, would be:

• 528.6 -- Leukoplakia of oral mucosa, including tongue, for the first lesion excision
• 528.72 -- Excessive keratinized residual ridge mucosa,for the excision of the additional margin, and
• 239.1 -- Neoplasm of unspecified nature of respiratory system, for the biopsy taken on the right side.

2: Compare RVUs to Find Primary Procedure

The procedure that carries the most relative value units by far (22.32) is the dermal autograft (15135, Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children); therefore, list this procedure first on the claim form with no modifiers.

Although the op note mentions a "split-thickness" graft, which you might consider coding as 15120 (Split-thickness autograft, face, ... first 100 sq cm or less ...), stick with 15135 since the surgeon used the split-thickness graft to close the defect created from the harvest of the dermal autograft, says Cobuzzi. This closure is inclusive in 15135.

3: Mention Muscle Excision for Best 40816 Odds

Next, most experts agree to code for the excision on the left side with 40816 (Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle, 10.2 RVUs). Append modifier 51 (Multiple procedures) to 40816 to communicate to the payer that the surgeon performed a separate, unbundled procedure in the same session (or on the same day).

Since the op note describes excision of the mass down to the depth of the muscle, it's reasonable to presume that a slim portion of muscle is captured with the excision, thus the selection of  40816, comments Rick Love, MD, otolaryngologist in private practice in Montgomery, Ala. The surgeon could make the op note clearer, however, by adding a brief mention of submitting a slim portion of fascia and muscle with the specimen to avoid an adverse decision on payment approval, Love says.

"I'm not 100 percent on board with the 40816 because the note states that it was excised down to the level of the muscle. It doesn't state that muscle was removed," comments Schade- Boyce. "Based on the documentation, I'm leaning towards 40814- 51 (Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair; Multiple procedures, 9.66 RVUs)."

Follow up: To be precise, check the pathology report to see if muscle tissue was examined, and then go back to the surgeon and question the verbiage in the op report, Schade-Boyce advises.

4: Weigh the Case for 40810

Consider whether to code the second, additional excised margin as 40810-59 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair; Distinct procedural service, 5.11 RVUs). "Many surgeons might be inclined to not add this code at all, having heard argument elsewhere that 'margins' were included in excision," says Love.

Rule: According to CPT language, excision code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that most narrow margin required for complete excision, explains Love. "Some find this confusing and have debated whether this would include several more added resection 'margins.'"

This case shows, however, that "there was cause, after further observation, for an additional excisional effort beyond the excision of the first lesion [and] the initial margins," Love adds. Furthermore, the extra margins also represent additional keratinized mucosa, notes Cobuzzi, separate from the leukoplakia, which helps justify modifier 59 for the separate site. "The prudent surgeon would add such explanatory comments into the dictation ... leaving little left to debate," adds Love. (Note: Modifier 59 is appropriate because 40810 is bundled with both 40816 and 40814, whichever initial excision code is supported by pathology.)

5: Append 59 to Biopsy

Finally, code 40808 (Biopsy vestibule of mouth, 4.59 RVUs) for the biopsy taken on the right side.

Modifier: Append modifier 59 to 40808 rather than modifier 51. CPT codes 40808 and 40816 are distinct procedures in this instance because the excision was performed on the left side while the biopsy was performed on the right, notes Charles F.Koopmann, Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.

Use modifier 59 to communicate to the payer that the surgeon performed a separate and distinct procedure that is normally bundled with another reported code, adds Schade-Boyce. Without adding 59, "the payer would bundle the biopsy into the excision code," she says.

Conclusion: Bring it All Together

The final summary of coding is:

• 15135, for the dermal autograft
• 40816-51 (or 40814-51, depending on your interpretation or confirmation on whether there was excised muscle), for the lesion excision
• 528.6, for the above
• 40810-59 (potentially, depending on your interpretation), for the excision of the additional margin
• 528.72, for the above
• 40808-59, for the biopsy
• 239.1, for the above.