Question Multiple Lesion Excision question

Jessim929

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Hi Derm Coders!

I usually code Urology with a little derm here and there, so I'm looking for your expertise. One of my doctors has a patient with "multiple sebaceous cysts on his scrotum" that doctor wants to excise. I am finding conflicting information about how to bill that. One says to combine all like lesions into one size, and another says bill each lesion separately with -59 modifiers. What do you usually do?

The insurance is Nevada Medicaid, if that makes any difference.

Thank you!!!
 

csperoni

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Just curious - what reference stated to combine all like lesions into one size?
The guideline for repairs in the same area is to add together, but lesions should be coded separately. I feel like that is a nuance that a lot of people miss. Simple repairs are always included in the lesion removal. Intermediate and complex repairs are usually billable separately.
 

such78

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What would be the appropriate CPT code for excision of a sebaceous cyst on the scalp or on the face that is subdermal or deeper?

Answer:

Integumentary lesion excision codes pertain to the epidermis, dermis, and subcutaneous tissue, while musculoskeletal lesion excision codes pertain to subcutaneous, superficial or deep soft tissues. Code ranges 11400-11446 and 11600-11646 represent lesions that normally occur on the surface of the skin (epidermis) or near the surface of the skin (dermis), compared to the type of lesion (or tumor) that occurs in the subfascial or fascial tissue, muscles and joints, as listed in the musculoskeletal section. A sebaceous cyst is a skin lesion and may be very large, distending the skin and pushing into the subcutaneous fatty tissue, but it is a skin lesion, and therefore, should be coded using the integumentary lesion excision codes, depending on the size of the cyst.



I found this from my noteone ( from some articles)

When you are coding an excision of a mass or a lesion and CPT instructs you to code based on the total excised diameter what exactly does that mean? Let’s unpack that together in today’s article.
Here is the guideline from CPT (located just prior to the codes for excision of skin lesions: CPT 11400-CPT 11646:
Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on individual judgment. The measurement of lesion plus margin is made prior to excision.
So the excised diameter also referred to as the total excised diameter, of a lesion is the greatest measurement across the lesion plus the most narrow margin needed to ensure adequate excision. Below are a couple of tips to follow to calculate the lesion diameter accurately:

1) If the physician provides dimensions in terms of length and width (e.g., 7 cm x 3 cm), remember to take the greatest diameter (7 cm in this example). Do not add those measurements together or multiply them together – simply take the greatest measurement across to determine the greatest diameter across the lesion.

2) When calculating margins, remember that margins are typically all the way around the lesion (unless otherwise specified in the note). So if the physician says there is a 2 cm lesion excised with 0.3 cm margins, remember to add that 0.3 cm to both sides of the lesion when measuring across it to calculate your total excised diameter. In this example, 2.0 cm+0.3 cm+0.3 cm = 2.6 cm for the total excised diameter.

3) Be aware of the unit of measurement provided in the procedure note when calculating your total excised diameter. Most physicians will provide the measurements in centimeters which is good because the CPT codes are listed based on the total excised diameter in terms of centimeters. Sometimes you will see lesions measured in inches or millimeters, though. When that happens, you first need to convert the measurement from inches or millimeters to centimeters to calculate the total excised diameter and pick the correct CPT code. I enjoy math and am pretty accurate when making these conversions on my own, but I still choose to use a conversion calculator to ensure I get my measurements exactly right since this detail will determine the accuracy of my coding. There are plenty of great conversion calculators online free of charge –below are a couple of links to get you started:

4) Note that the most narrow margin to ensure complete excision is based on individual judgment according to these guidelines. So it’s up to the physician excising the lesion to determine how much margin to take and to provide you with this information. Coding Tip: If no margins are specifically provided in the procedure note, and the physician lists a measurement for the lesion (e.g., 3.0 cm), code the lesion excision with the understanding that the margins are already included in the measurement provided.

5) The measurement of the lesion plus margin is made prior to excision. This is an important because coders sometimes try to grab measurements for lesions from pathology reports when the measurements aren’t included in the procedure report. Why is that an issue? Tissue shrinks in formalin (the fluid that tissue is placed in when it is sent off to a pathology lab for analysis). So if you take the measurements from your path report, you will definitely calculate a smaller diameter across the lesion than you would if the physician takes these measurements prior to excision and documents them in the procedure report. If you are missing the total excised diameter and have the opportunity to query the physician, I would encourage you to do so. If you are in a situation where you cannot go back and ask the physician for the measurement, you could take the measurements from the pathology report as a last resort, but be aware that, in doing so, the measurement across the lesion will be smaller and less accurate than it would be if documented in the procedure report.

6) Each lesion excised separately is measured individually following the tips above. Do not add the total excised diameter of multiple lesions together unless one large excision encompassing two lesions that are close together is documented. This is not very common, but it does happen so it bears mentioning here. Otherwise, you will assign multiple CPT codes based on the nature of the lesion (benign vs. malignant), the anatomic site, and the total excised diameter of each individual lesion.


Additionally, I am checking 3M, and also found this,


Lesion excision clarifications
CPT Assistant, September 2018 Page: 7 Category:

Coding Tip

Excision of benign subcutaneous soft tissue tumors (lesions) of cutaneous origin (eg, sebaceous cyst) are reported with excision of benign lesions codes (11420-11426) from the Integumentary System. Radical resection of soft tissue tumors that have a cutaneous origin are reported with excision of malignant lesions codes (11600-11646) from the Integumentary System.



While the code series of 11400-11471 and 11600-11646 (benign and malignant integumentary lesion excisions) are appropriate to report for excisions of cutaneous lesions, as well as superficial subcutaneous lesions such as cysts and scars, when the lesions are located in deep subfascial or submuscular tissues, the appropriate code from the Musculoskeletal System should be reported. For example, code 27618, Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm, should be reported for the excision of a deep subcutaneous mass in the posterior aspect of the left ankle.

In summary, review the following coding tips to help select the appropriate excision codes for the both integumentary and musculoskeletal systems.

•Report the size of the lesion at its maximum diameter in addition to the sum of the narrowest margins used to excise the lesion.

•Select a code from the appropriate section: Eg, benign (11400-11446) or malignant (11600-11646) for integumentary lesions, or the anatomically appropriate excision code for musculoskeletal soft tissue tumors (eg, codes 23071-23078 in the Shoulder subsection).

•Select from codes 11400-11446 for excision of benign lesions of cutaneous origin (eg, sebaceous cyst).

•Report vessel exploration and/or neuroplasty separately, when performed.

•Use documentation of the depth of the lesion to determine whether codes from the Integumentary System or Musculoskeletal System are appropriate to report.

•Append modifier 59, Distinct Procedural Service, to the second and subsequent codes when multiple lesions are excised regardless if they are in the integumentary or musculoskeletal systems.

•Determine what type of procedure is being performed before making a code selection. For example, in the Integumentary System section, the difference between excision and other techniques (eg, biopsy, debridement, shave removal) is that excision requires the removal of the entire full thickness of the dermis through to the subcutaneous tissue.
 
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Jessim929

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Just curious - what reference stated to combine all like lesions into one size?
The guideline for repairs in the same area is to add together, but lesions should be coded separately. I feel like that is a nuance that a lot of people miss. Simple repairs are always included in the lesion removal. Intermediate and complex repairs are usually billable separately.

I'm starting to think it was a comprehension error on my part. :)
 

csperoni

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I'm starting to think it was a comprehension error on my part. :)
Whenever the opportunity presents itself, I point this out because it was something that I personally kept confusing for way too long until I realized this. If you don't code lesion removal or repairs on a regular basis, you know there's a guideline, but don't realize the guidelines are the opposite for repairs and lesion removals.
 

Jessim929

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Whenever the opportunity presents itself, I point this out because it was something that I personally kept confusing for way too long until I realized this. If you don't code lesion removal or repairs on a regular basis, you know there's a guideline, but don't realize the guidelines are the opposite for repairs and lesion removals.
You're SO right. I work in Urology, so if they excise anything, it's usually a one and done. This was a first for me.
 
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