Primary Care Coding Alert

Faced with a host of new 2003 directives, family physician coders who already cite lesion excisions as one of their top problems will confront even greater challenges to ethically maximize reimbursement without double-billing. But you can x out billing errors by knowing the lesion's type, size, location, and how to bill for multiple excisions and closures. (For more advice, see "Lesion 101: Uncover Excision Basics" in article 2.) Remember Beauty and the Beast When selecting a lesion excision code (11400-11646), you should first identify the lesion type. Family physicians often treat benign skin lesions, such as noncancerous growths, cicatricial (scar), fibrous, inflammatory, congenital (birth) and cystic lesions. In addition, they may treat malignant lesions, such as basal cell carcinoma, squamous cell carcinoma and melanoma. CPT divides excisions into two subsections: benign (11400-11471) and malignant (11600-11646). "You should select the category based on whether the lesion is determined to be benign or malignant," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. But how can you choose a code when you don't know the lesion's pathology? "If the physician is confident that the lesion is benign, you can bill without the pathology report," she says. On the other hand, if the physician is concerned that the lesion might be malignant, you should wait for the report. That way, you don't label the patient with an incorrect diagnosis that could affect his ability to get future insurance coverage. Determine Location Once you have narrowed your choice to the correct pathology category, you should focus on the lesion's location. Both the benign and malignant subsections subdivide lesions into three body areas: 1. trunk, arms or legs (11400-11406, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs ...; 11600-11606, Excision, malignant lesion including margins, trunk, arms, or legs ); 2. scalp, neck, hands, feet, genitalia (11420-11426, benign; 11620-11626, malignant); and 3. face, ears, eyelids, nose, lips, mucous membrane (benign only) (11440-11446, benign; 11640-11646, malignant). For a visual breakdown of the codes, see the chart in article 2. Size and Margins Matter Now that you're in the right group of codes based on body site, the proper measurement will land you with the perfect score. Within each body area, you have six codes to select from depending on the excised diameter including margins. But you must first remember the measurement rules for 2003. Previously, you chose the code based on the lesion's diameter only, says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions, a physician reimbursement company in Lakewood, N.J. CPT 2003 expanded the measurement rules to include the narrowest margins required to excise the lesion. So the new codes refer [...]