Podiatry Coding & Billing Alert

If your payer consistently denies claims you submit for foot tumor excisions, perhaps you should be using a lesion debridement, lesion shaving, or lesion excision code instead.

Many coders erroneously report lesion debridement or excision as foot tumor procedures, said John P. Heiner, MD, of the American Academy of Orthopedic Surgeons (AAOS) Coding, Coverage, and Reimbursement Committee at the CPT and RBRVS 2010 Annual Symposium in Chicago.

The confusion apparently stems from a lack of understanding of the differences between the two conditions, and the corresponding codes for shaving, excision, and resection methods. Here are a few pointers to help you pin the codes down and avoid future denials:

Podiatrists treat lesions in one of several ways: debridement, shaving, or excision. To distinguish among the procedures, you must consider how deep the podiatrist must go to remove the lesion from the foot.

Check this out: 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. The CPT provides the following debridement codes for lesions:

• 11000 -- Debridement of extensive eczematous or infected skin, up to 10% of body surface;

• 11040 -- Debridement; skin, partial thickness;

• 11041 -- ... skin, full thickness;

• 11042 -- ... skin, and subcutaneous tissue;

• 11043 -- ... skin, subcutaneous tissue, and muscle; and

• 11044 -- ... skin, subcutaneous tissue, muscle, and bone.

What's different: In contrast, excision is 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.

Podiatrists remove tumors through either 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 the large area covered by the procedure.

The distinguishing point for shaving/debridement/excision versus radical resection is whether the podiatrist has to go above or below fascia (a sheet or band of fibrous connective tissue), said Albert E. Bothe, Jr., MD FACS, executive vice president and chief quality officer for the Geisinger Health System and member of the American College of Surgeon's General Surgery Coding and Reimbursement Committee, at the Symposium. Subcutaneous tissues are usually above deep fascia. When the podiatrist removes tissues below fascia, then he is getting into radical resections, Bothe added.

To determine the correct code for either a lesion or tumor procedure, it is important that your podiatrist's operative report indicates the size, depth, and location of each growth, says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC of Hampton, Va. Accurately determining lesion or tumor size will also ensure that your podiatrist gets properly compensated for the depth and difficulty of the service he provided. Lesions vary in sizes but for the feet, CPT 2010 provides codes for specific sizes of epidermal or dermal lesions as follows:

• 11305-11308 -- Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia ... -- lesion diameters ranging from 0.5 cm or less to over 2.0 cm

• 11420-11426 -- Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ... -- excised diameters ranging from 0.5 cm or less to over 4.0 cm

• 11620-11626 -- Excision, malignant lesions including margins, scalp, neck, hands, feet and genitalia ... -- excised diameters ranging from 0.5 cm or less to over 4.0 cm.

Take note: Lesion size determines the proper CPT code to use and, therefore, the proper payment. You also have to remember that in determining the lesion size, your podiatrist must add the size of the surrounding margins that were removed.

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.' Tumor removal codes fall under the 20000 code series. You must also check for indications of the size of the excised tumor since CPT 2010 provides codes for specific sizes , as follows:

• 28039 -- Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater;

• 28041 -- Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); 1.5 cm or greater;

• 28043 -- Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm;

• 28045 -- Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); less than 1.5 cm;

• 28046 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot or toe; less than 3 cm; and

• 28047 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot or toe; 3 cm or greater.