Otolaryngology Coding Alert

Question: One of our otolaryngologists excised a lesion from a patient’s nose with an excised diameter of 1.2 cm. They intend to do an adjacent tissue transfer (ATT) for minimal scarring but wait for the pathology report to determine if the lesion is malignant and to ensure clear margins. Assuming we get a pathologic diagnosis of basal cell carcinoma (BCC) with margins clear, and the ENT performs the ATT four days later, how should we code this encounter?

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Answer: You should code the initial procedure with 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm) and associate it with C44.311 (Basal cell carcinoma of skin of nose) for the initial diagnosis of BCC.

Coding tip 1: Sometimes, the surgeon indicates round measurements instead of specifying the actual, precise measurements. This can cause the case to be under- or overcoded, which may put your practice at risk of losing revenue or receiving improper payments, creating compliance problems.

For example, if the surgeon rounds the measurement down to 1 cm in this encounter, you would be forced to code the procedure as 11641 (… excised diameter 0.6 to 1.0 cm). The 2026 national nonfacility fee for 11641 is $237.15, whereas the fee for 11642 is $266.87, a difference of $29.72. So, you should remind your ENTs of the implications of inaccurately measuring and documenting the excised diameter of the lesion.

If it is performed four days later, the correct code for the tissue transfer will be 14060 (Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less). You’ll assign Z42.8 (Encounter for other plastic and reconstructive surgery following medical procedure or healed injury) as the principal diagnosis and Z85.828 (Personal history of other malignant neoplasm of skin) as a secondary diagnosis on the claim for the ATT.

Coding tip 2: The tissue transfer will happen during the excision’s 10-day global period, so reporting 11642 and then 14060 on its own four days later will result in a denial. However, you can overcome bundling issues by reporting the second surgery with modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period), as the ATT was a planned, staged procedure — the ENT waited for pathology results before closing the defect — and does not require a return to the operating room.

Remember: When you use modifier 58 for 14060, the global period restarts, so your surgeon should get 100 percent of the fee schedule payment for the service submitted with modifier 58. Had the closure via ATT taken place on the same day as the lesion removal, you would only be able to code the closure because adjacent tissue transfer/rearrangement codes include lesion excision. This is because CPT^® considers the lesion excision preparation for the ATT or rearrangement.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC