Pediatric Coding Alert

You’ll use modifiers 59, 51—depending on payer preference.

If a patient reports for removal of multiple lesions, you need to check if the removals are of the same type or from the same part of the body.

Rationale: Some of these claims will result in multiple codes, while others will require you to add total repair length and code based on that number. Once you’ve figured all that out, you’ll have to tackle the modifierquestion.

Coding conundrum:  When you’re choosing a modifier for these multiple lesion excisions, “it often depends on the payer,” explains Joan Gilhooly, MBA, CPC, CPCO,  president and consultant for Medical Business Resources, LLC in Lebanon, Ohio. Check out this expert advice on choosing the right codes and modifiers in these common multi-lesion removal situations.

I.D. Lesion Anatomy, Benign/Malignant Status

For coding purposes, CPT^® breaks lesion removal coding into three body areas. When you are coding for multiple lesion removals within the same identified body area, you should choose from the following code sets:

• 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) through 11446 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm) for benign lesions.
• 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less) through 11646 (Excision, malignant lesion including margins, face, ears eyelids, nose, lips; excised diameter over 4.0 cm) for malignant lesions.

When your physician removes multiple lesions of the same type from the same body area, you should be able to report multiple codes for the excisions.

Caveat: You have to prove that the excisions weren’t surgically related before considering multiple codes, Gilhooly warns. The notes must prove that the lesion removals are truly separate. If the removal was one long, contiguous lesion, add the entire length of the repair and report a single code based on that length.

Example: Let’s say your physician excises three benign lesions: one from a patient’s upper left arm measuring 1.1 cm, one from her left thigh measuring 0.9 cm, and one from her left calf measuring 0.3 cm.

On this claim you should report 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) for the upper arm lesion, 11401 (… excised diameter 0.6 to 1.0 cm) for the thigh lesion, and 11400 (… excised diameter 0.5 cm or less) for the calf lesion.

Choose Modifier, Then Complete Multi-Excision Claims

Since the excisions occurred in the same body area in the previous example, you’re going to need to use a modifier on 11401 and 11400. Modifier 51 (Multiple procedures) might apply for most payers, but be sure they don’t want modifier 59 (Distinct procedural service) instead, Gilhooly warns. And even here, you have a new layer of modifier mayhem with the new X modifiers. Many payers are currently being flexible with the coders allowing use of the 59 or the new X{ESPU} modifiers that allow for more description of the situation.

Additional modifier alert: For greater coding specificity, some payers might request that you also append modifier LT (Left side) to 11402, 11401, and 11400.

Best bet: If you’re unsure about which modifier you should use when coding multiple lesion removals from the same body area, Gilhooly recommends two courses of action:

1. Contact the payer, or check your contract, to see if you should use 51 or 59 (or XE, XS, XP, XU) in these lesion excision situations.

2. If you can’t get clarification from the payer, Gilhooly recommends that you go straight to the Correct Coding Initiative (CCI) edits. If there is no code pair in the CCI edits, use 51.