lesion size 7cm X 7cm

TxDerm

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Can someone tell me what cpt code to use for a benign lesion on the buttocks, lesion size was 7cm X 7cm, but i only see the CPT code goes up to 11406 (excised over 4cm)
is this the highest code to bill with----
 

cgaston

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Anything over 4 cm is technically "increased procedural service" so a -22 modifier could be used.

However, since you don't want to overuse the -22 modifier we have a general rule here. We have determined that if the excision is 8 cm or more (double the size) we submit the bill with -22 modifier and the operative report.

I think it is a shame that we have to worry about overuse when we have cases where the modifier is appropriate but that is what happens when codes are used for reimbursement purposes instead of informational purposes.
 

CodingKing

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Anything over 4 cm is technically "increased procedural service" so a -22 modifier could be used.

I don't agree on modifier 22 in the situation. The code selection options are very specific in sizes. 4 or more reads as 4 to infinity so the code (and RVU) were set to take larger than 4 into account. I don't think modifier 22 should even be considered, my guess is its capped at this size since the code includes simple closure and a lesion of this size isn't typically closed with simple closure thus the extra work is captured in a separately payable code.

Here is some good additional information on things to think about when considering modifier 22

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/clarification-use_modifier22.shtml

For example:

An appropriate use of the -22 modifier is when a procedure is truly more complicated that the standard one, although it is not necessarily harder in the usual sense. In this instance, one is probably performing two procedures, rather than one. An example would be the laparoscopic "take down" of a prior hiatal hernia repair (and there is no such code for this) and the performing of a new, different type of hernia repair. There obviously is more work involved in this "double surgery."
 

cgaston

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Please allow me to rephrase my answer:

My office has interpreted that any lesion removal over 8 cm warrants the addition of the -22 modifier and we have been instructed to code it as such. Your interpretation may vary.
 

CodingKing

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Please allow me to rephrase my answer:

My office has interpreted that any lesion removal over 8 cm warrants the addition of the -22 modifier and we have been instructed to code it as such. Your interpretation may vary.

do you actually get paid for the extra work?
 

thomas7331

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My office has interpreted that any lesion removal over 8 cm warrants the addition of the -22 modifier and we have been instructed to code it as such. Your interpretation may vary.

I agree with CodingKing's 'interpretation' here. The code definition already includes lesions over 8 cm, and the RVU value assigned to the code would have been calculated to include compensation for that. It would not be standard coding practice to automatically assign this modifier to a subset of procedures that are already included in the code definition. Anyway, most payers will require documentation of something specific to the case (e.g. increased time, anatomical difficulties) that supports increased procedural work in order to allow any extra payment for modifier 22.
 
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