This is the case:
Today I had a patient with an invasive squamous cell carcinoma of the scalp. The lesion was deeply and broadly invasive with evidence of invasion to galea (the fascia of the scalp between the skin and the skull). Because pathology findings required immunostains to determine margin status, I converted the case from a Mohs case to an excision/resection case because I was sending the specimen for margin assessment by a dermatopathologist who could perform immunostains on permanent (non-Mohs) sections. Because I was not performing margin assessment myself, I could not bill Mohs. I biopsied an adjacent nodule, had it processed by frozen section, and diagnosed invasive squamous cell carcinoma with evidence of likely micrometastasis with histologic evidence of likely involvement of galea or at least the interface of the reticular dermis and the galea. Because the two tumors were so close together, when I removed them their defects merged into a single large defect. I took a wide margin that included full thickness of skin, fat and galea leaving a final defect that was very large (10.2 x 7.3cm in size).
I then performed a layered closure involving wide-undermining, a deep layer of sutures involving fascia and dermis and a top layer of sutures involving epidermis and dermis that measured 12cm in size, but the defect was so large that the center had to be left to granulate in (heal by second intent). Periosteum was visible in the center of the defect.
My questions primarily concern the differences between excision codes and radical resection codes and when a radical resection code can be used.
First, to determine whether to use a radical resection code, which of the following matter(s):
A) the cell origin of the tumor. For example, tumors derived from skin include squamous cell carcinomas. Tumor derived from mesoderm include leiomyosarcomas. Are radical resection codes only for non-skin derived tumors or can they be used for squamous cell carcinoma?
B) the structures the tumor is clearly involving on histology or clinically: e.g., are radical resection codes only for tumors involving at least fascia such as the galea of the scalp? or at least muscle (in most of the scalp the galea and periosteum are the only layers between skin and skull and no muscle is present)? or skull itself?
C) the structures removed as part of the excision / resection: e.g., even if you don't have definitive histologic evidence that galea is involved, if you cut through and remove a block of tissue including skin, fat and galea leaving behind only periosteum and skull, would a radical resection code apply?
D) the specialty of the doctor. Are radical resection codes really only to be billed by orthopedic sugeons and likely to be denied if billed by a dermatologist because excision codes are in the 10000-series (integument) whereas radical resection codes are in the 20000-series (musculoskeletal)?
Second, do radical resection codes include the repair code such that you are not allowed to bill for a complex layered closure in addition to a radical resection code?
Third, when a layered closure with wide undermining is performed but some areas are left to granulate in, can a complex layered closure still be billed even though some healing is by second intent?
Fourth, if the margins are positive and I have to excise more tissue and then perform another closure at a later date, can I then bill for an excision or radical resection and a closure again?
Fifth, which codes are appropriate in this case: 21016 or 11626? 13121 and 13122? 11100? 88331?
Today I had a patient with an invasive squamous cell carcinoma of the scalp. The lesion was deeply and broadly invasive with evidence of invasion to galea (the fascia of the scalp between the skin and the skull). Because pathology findings required immunostains to determine margin status, I converted the case from a Mohs case to an excision/resection case because I was sending the specimen for margin assessment by a dermatopathologist who could perform immunostains on permanent (non-Mohs) sections. Because I was not performing margin assessment myself, I could not bill Mohs. I biopsied an adjacent nodule, had it processed by frozen section, and diagnosed invasive squamous cell carcinoma with evidence of likely micrometastasis with histologic evidence of likely involvement of galea or at least the interface of the reticular dermis and the galea. Because the two tumors were so close together, when I removed them their defects merged into a single large defect. I took a wide margin that included full thickness of skin, fat and galea leaving a final defect that was very large (10.2 x 7.3cm in size).
I then performed a layered closure involving wide-undermining, a deep layer of sutures involving fascia and dermis and a top layer of sutures involving epidermis and dermis that measured 12cm in size, but the defect was so large that the center had to be left to granulate in (heal by second intent). Periosteum was visible in the center of the defect.
My questions primarily concern the differences between excision codes and radical resection codes and when a radical resection code can be used.
First, to determine whether to use a radical resection code, which of the following matter(s):
A) the cell origin of the tumor. For example, tumors derived from skin include squamous cell carcinomas. Tumor derived from mesoderm include leiomyosarcomas. Are radical resection codes only for non-skin derived tumors or can they be used for squamous cell carcinoma?
B) the structures the tumor is clearly involving on histology or clinically: e.g., are radical resection codes only for tumors involving at least fascia such as the galea of the scalp? or at least muscle (in most of the scalp the galea and periosteum are the only layers between skin and skull and no muscle is present)? or skull itself?
C) the structures removed as part of the excision / resection: e.g., even if you don't have definitive histologic evidence that galea is involved, if you cut through and remove a block of tissue including skin, fat and galea leaving behind only periosteum and skull, would a radical resection code apply?
D) the specialty of the doctor. Are radical resection codes really only to be billed by orthopedic sugeons and likely to be denied if billed by a dermatologist because excision codes are in the 10000-series (integument) whereas radical resection codes are in the 20000-series (musculoskeletal)?
Second, do radical resection codes include the repair code such that you are not allowed to bill for a complex layered closure in addition to a radical resection code?
Third, when a layered closure with wide undermining is performed but some areas are left to granulate in, can a complex layered closure still be billed even though some healing is by second intent?
Fourth, if the margins are positive and I have to excise more tissue and then perform another closure at a later date, can I then bill for an excision or radical resection and a closure again?
Fifth, which codes are appropriate in this case: 21016 or 11626? 13121 and 13122? 11100? 88331?