Multiple lesions on face, different sizes

cs72410

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I have a dilemna. I am coding a patient encounter...No office visit to be billed, just the procedures to remove (3) lesions.

Per the notes I have, there are 3 lesions - one on the side of the eye, and the other under the eye, and the third lesion is on the forehead.

The lesions near the eye are both .5cm and were described simply as "skin lesions rule-out basal cell CA", and the lesion on the forehead is 1cm and is described as "Actinic Keratosis" - per the notes, the sizes included the margin.

The method to remove these lesions was shaving.

Here's how I think it should be coded:

11311, dx 702.0
11310-59, dx 709.9
11310-59, dx 709.9

I feel like I'm missing something, though...the payer may think it was just a mistake of someone putting the 11310-59 twice, when in fact they are 2 diffent lesions...can there be both a modifier 51 & 59 on the same procedure?? Should it be coded like this:

11311, dx 702.0
11310-59, dx 709.9
11310-51-59, dx 709.9

Any help would be greatly appreciated...Thanks!!
 

gayle05

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If the insurance company follows the CCI guidelines no modifiers really need to be used. I wouldn't use ICD9 709.9 for the diagnosis. If bx's would have been performed on the R/O BCC you could use 238.2 but since shaves were done the charges should be held until the pathology results come back. I know some practices just bill the shave's with 238.2 prior to receiving the path results and don't have problems with payments. There is alot of discrepancy regarding the use of 238.2 so if any one out there has updated news for the use of this code I would greatly appreciate it.
 

gayle05

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Sorry your question really wasn't about the codes but that's the first thing that I noticed. Regarding your question about billing 11310 in units or separately, you can bill as units just make sure when you are reimbursed the allowables are correct. Our practice has billed codes both ways.
 

Jen Verlinda

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Regarding your quote "The lesions near the eye are both .5cm and were described simply as "skin lesions rule-out basal cell CA".

I am assuming these are being sent for path, in this case you could use biopsy codes since the biopsy includes "shave removals". I would code as follows:

13100 702.0
11100-59 238.2
11101-59 238.2

The -51 mod would not apply to the 11101 since it's an add on code. Also, I'm in WA state and our payors pay without waiting for path.

Hope this helps!
Jen Verlinda, CPC
 

mitchellde

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If the insurance company follows the CCI guidelines no modifiers really need to be used. I wouldn't use ICD9 709.9 for the diagnosis. If bx's would have been performed on the R/O BCC you could use 238.2 but since shaves were done the charges should be held until the pathology results come back. I know some practices just bill the shave's with 238.2 prior to receiving the path results and don't have problems with payments. There is alot of discrepancy regarding the use of 238.2 so if any one out there has updated news for the use of this code I would greatly appreciate it.
238.x dx codes are to be used after pathology is obtained with the result of uncertain behavior. It is not that the provider is uncertain what the path will be, rather it is that the cellular activity observed under a microscope is uncertain as to what it is. Therefor you do not use a 238.x code unless you have the path report. When the provider states to R/O BCC, then the dx code you have is 709.9. You are not required to hold a shave and wait for the path although I feel it is advisable, You are required to hold an excision and wait for the path.
 

mitchellde

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Regarding your quote "The lesions near the eye are both .5cm and were described simply as "skin lesions rule-out basal cell CA".

I am assuming these are being sent for path, in this case you could use biopsy codes since the biopsy includes "shave removals". I would code as follows:

13100 702.0
11100-59 238.2
11101-59 238.2

The -51 mod would not apply to the 11101 since it's an add on code. Also, I'm in WA state and our payors pay without waiting for path.

Hope this helps!
Jen Verlinda, CPC
I fthe documentation states a shave was performed you cannot code it as a biopsy. The definition of a shave is a partial thickness removal of the entire visible anomaly, and a biopsy is a removal a piece of a lesion and can be done to a depth of partial thickness or full thickness,
Also I I indicated above you cannot use a 238.x dx code, first of all it is not documented and second you have no path which indicates uncertain behavior.
We must always code only what is documented and not try to read more into it.
 

cs72410

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multiple lesion removal

Thanks everyone for your insight! This was a tough one for me! I didn't think I could use the biopsy codes because I read in CPT that for some surgical procedures in the integumentary system...removed tissue is often submitted for path exam...and the biopsy is considered a routine component of such procedures. The diagnosis was throwing me off because of it saying "Skin lesion" and "Actinic Keratosis" - but also saying R/O Basal Cell carcinoma...I think that PART kept sticking in my head!!

I appreciate all the input! This is a great organization and I love the forums! The coding community is so helpful to each other...and it's especially great because everyone has a different way of looking at things! Thanks again

;)
 

Jen Verlinda

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These forums are a great way to "network".

I do have a response in regards to the biopsy vs. shave removals. Per CPT under Biopsy it states "During certain surgical procedure in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination". This would allow the 11100 and 11101 codes. Inga Ellzey has touched on this topic many times.

Thanks. :)

Thanks!
 

mitchellde

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These forums are a great way to "network".

I do have a response in regards to the biopsy vs. shave removals. Per CPT under Biopsy it states "During certain surgical procedure in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination". This would allow the 11100 and 11101 codes. Inga Ellzey has touched on this topic many times.

Thanks. :)

Thanks!
Submitting a specimen to pathology is not the same thing as a biopsy. A biopsy is a procedure which is defined as a piece of the lesion removed either full or partial thickness. You cannot charge a biopsy just because it goes to pathology. The statement you are referring to does not say to bill a shave as a biopsy, it just tells you that these specimens are often submitted for a path review.
 

DeeCPC

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I agree with Debra. I read Inga Elzey all the time and I have not seen anything contradicting Debra's take on this matter. I have coding books from the AAD that are very clear on the subject as well.

Dee, CPC, CPCD
 
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Quantity

But how about if the case is, the only diagnosis I have are 706.9 ang 686.09 and they are claiming 11310 x 5? Can we pay all the procedure? Just for your information here in Abu Dhabi, we do not have any modifier. please help.

thanks!
 
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mitchellde

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But how about if the case is, the only diagnosis I have are 706.9 ang 686.09 and they are claiming 11310 x 5? Can we pay all the procedure? Just for your information here in Abu Dhabi, we do not have any modifier. please help.

thanks!
If you are billing for US payers using CPT codes then you do use modifiers. I can assist better with more information, such as whom are billing to and what exactly the note states was removed, and where and by what what method.
 

manablo

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Sorry your question really wasn't about the codes but that's the first thing that I noticed. Regarding your question about billing 11310 in units or separately, you can bill as units just make sure when you are reimbursed the allowables are correct. Our practice has billed codes both ways.
This is confusing- units vs. separately. I am being told both ways. If done by units you add up the size's of all the lesions in one area. Then my manager says that you have to list each lesion separately. Which way is correct?

Can you e-mail me at nabloma1@memorialhealth.com

Thank you so much
 
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