Primary Care Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: How should I code for the removal of a skin nodule on the back and neck with sutures for a two-centimeter incision?

Linda Slagle
Campbellsville Family Medicine, Ky.


Answer: There are several factors to consider when you report the removal of skin nodules on the back and neck with sutures.

Excision of benign lesions of the back would be coded from the 11400-11406 series. The specific code depends upon the diameter of the lesion itself, which should be documented by the physician in the patient record. If the lesion is two centimeters in diameter, for instance, you would assign 11402 (excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 1.1 to 2.0 cm).

For the lesion on the neck, the same process would be used, and a code from the 11420-11426 series would be chosen.

Both of these series are assigned with a simple closure of the incisional wound. Should the incisional wound have to be closed in two or more layers, you would report the appropriate repair (closure) code.

If the repair was categorized as intermediate one or more of the deeper layers of subcutaneous tissue and superficial fascia in addition to the skin closure you would code 12031 for the back (layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) and 12041 for the neck (layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less).

If the repair was categorized as complex requiring more than a layered closure, scar revision, debridement, extensive undermining, stents or retention sutures you would code 13100 (repair, complex, trunk; 1.1 cm to 2.5 cm) for the back, and 13131 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm) for the neck.

CPT notes that when more than one classification of wounds are repaired, the more complicated repair should be listed as the primary procedure and the less complicated as the secondary procedure, with modifier -51 (multiple procedures) appended to indicate multiple procedures.

Editors note: This question was answered by Lamon Willis, CPC, who specializes in physician billing and coding as a healthcare consultant for St. Anthony Consulting Group in Florida.