Podiatry Coding & Billing Alert
Navigate the Nuances of Coding for Lesions Versus Tumors
Understand the difference before you code. Was that a lesion or a foot tumor your podiatrist just treated? How do you know the difference? Without clear documentation, your provider risks missing out on valid claim reimbursement due to the inability to accurately capture the work performed. Ultimately, from a coding perspective, the difference between a lesion and a tumor is less important than determining the method a provider uses to remove the abnormal tissue growth. But it is still helpful to look at the clinical definitions for the conditions. Know the Lesion/Tumor Difference The term “lesion” broadly refers to any abnormal tissue area, a wound, acute inflammation, a burn, to an extensive cancerous growth, or even a congenital structural anomaly. Lesions can either be observed with the naked eye or only be detectable under a microscope. More importantly, the label “lesion” does not provide any indication of the likely outcome or prognosis. A tumor on the other hand, more specifically refers to an abnormal outgrowth of tissue. To code correctly for the different removal procedures, you need to grasp just when you should be using a debridement, shaving, or excision code. Here are a few pointers to help you pin down the correct codes and avoid future denials. Pay Attention to Lesion Removal Procedures Podiatrists treat lesions either by debridement or shaving. To distinguish between the procedures, you should consider how deep the podiatrist must go to remove the lesion from the foot. Debridement is the surgical removal of diseased or contaminated tissue or skin. Shaving is the removal of dead skin using a slicing or sawing motion. You can use the following debridement codes for lesions: For shaving, you would choose a code from the 11305-11308 series. Depending on the size of the lesion, you’ll report one of the following codes: Look to Excision and Resection Codes for Tumor Removals On the other hand, when your podiatrist removes a tumor on a patient’s foot, toe, or ankle, you must check the medical documentation for numerous details; including the size of the tumor, the depth of the tumor removal, and whether the podiatrist performed an excision or radical resection. Podiatrists remove tumors via excision or radical resection (excision of all or part of an organ or tissue, along with the blood supply and lymph system supplying the organ or tissue). Radical resection generally applies to malignant tumors. One clue in your podiatrist’s documentation that would indicate a radical resection is if a large area is covered by the procedure. Excisions, on the other hand, are the surgical removal of an organ or tissue (lesion or tumor) through an incision as deep as or deeper than the full thickness of the skin. Unlike shaving, excisions require suturing to allow the surgical wound to heal. The distinguishing point for shaving/debridement/excision versus radical resection is whether the podiatrist must go above or below the fascia (a sheet or band of fibrous connective tissue). Subcutaneous tissues are usually above deep fascia. When podiatrists remove tissues below fascia, then they are getting into radical resections. Note These Distinct Tumor Removal Codes If your podiatrist specifies tumor removal, you must check the patient’s records for indications that the mass is musculoskeletal in origin, such as a reference to “soft tissue.” You must also check for indications of the size of the excised tumor since CPT® provides codes for specific sizes, as follows: “When coding the difference in lesion excision 280xx codes, the key is depth and additional structure invasion. For subfascial tumors, these tumors specifically involve the tendons, tendon sheaths, or joints of the digit. Tumors that merely touch but do not breach these structures are categorized as subcutaneous soft tissue tumors,” says Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC. Bella Vista, Arkansas. Review Radical Resection Radical resection is the surgical removal of a structure to include its vascular supply, associated lymph nodes, and a sufficient margin of surrounding tissues, especially around a tumor, to ensure that all diseased tissue is removed. Radical resection generally applies to malignant tumors. If the podiatrist performs radical resection of a tumor, such as a sarcoma, on a patient’s ankle, then you would report the following codes: On the other hand, if your podiatrist performs a radical resection of a foot or toe tumor, you should report one of the following codes: See Why Size Does Matter No matter whether your podiatrist is removing a lesion or tumor, however, it’s essential that the podiatrist’s operative report specifies each growth’s size, depth, and location. Precise measurement of the lesion or tumor not only aids in correct coding, but also guarantees appropriate compensation for the podiatrist, reflecting the complexity and depth of the service rendered. “It is important to have the exact measurement prior to sending the lesion or tumor off to pathology, as the sample will shrink once removed. If measured based on a pathology report then you will not be compensated accurately,” says McNamara. For example: A provider removes an 0.8 cm a benign lesion from a patient’s right foot by creating an elliptical incision down to the fascia with margins of 0.2 cm. The provider closes the surgical site with six sutures. In this case, the code for lesion removal should consider the size of the lesion in addition to twice the measurement of the smallest surgical margin. In our example, the lesion is 0.8 cm, but the margins add on an additional 0.4 cm (2 x 0.2 cm). This gives a total excised diameter of 1.2 cm, which means you would use 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). Take note: “Coding guidelines instruct to code based on greatest diameter, and if no margins are documented, we will only be able to capture the size based on the largest diameter. For example, a 1.5 x 3 cm excision without margins will get you only 3 cm or 11423 [Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm] but with additional margins of .5 on each side we can get credit for 11424 [… excised diameter 3.1 to 4.0 cm],” says McNamara.
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