Wart Excision with Flap Repair

djreiff

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Good morning!

I have run into an issue with billing for a wart removal that resulted in the physician having to perform a rotational rhomboid-type flap repair. The wart required the flap closure due to location and size. See the operative report below.

We billed just the 14040 for the repair, as the excision is included, but the insurance company (Blue Cross) is denying stating that the diagnosis of plantar wart doesn't substantiate the CPT code billed. I tried to appeal with records for medical necessity, explaining that the defect required a more complex type of closure. But they upheld that denial.

Any suggestions on coding for this?


PREOPERATIVE DIAGNOSIS:
Plantar wart, left forefoot.
POSTOPERATIVE DIAGNOSIS:
Plantar wart, left forefoot.
PROCEDURES:
1. Local rotational flap rhomboid-type flap.
2. Excision of plantar wart, left foot.

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
Less than 25 mL.

COMPLICATIONS:
None.

INTRAOPERATIVE FINDINGS:
Intraoperatively there was noted to be a well-circumscribed plantar wart in the plantar aspect of the left foot. Measured approximately
1 cm in diameter.

DESCRIPTION OF PROCEDURE:
Patient was brought to the operating room and placed on the operating table in supine position. Following adequate anesthesia via
general anesthesia, left lower extremity was prepped and draped in usual sterile manner. Left lower extremity was then elevated,
exsanguinated, and ankle tourniquet inflated to 250 mmHg. Attention directed in the plantar aspect of the left foot where this lesion
was excised circumferentially, was measured approximately 1 cm in diameter. After full excision, the lesion was sent to Pathology.
The rhomboid flap on either end of the proximal and distal extents of the lesion were then elevated and rotated into place for proper
closure. The wound and defect as well as the flap were sutured in place using 4-0 nylon stitch after flushing with copious amounts of
sterile saline. Sterile dressings were then applied after infiltrating with Marcaine. She left the operating room for recovery room with
vital signs stable and vascular status intact. She was given postop instructions, postop pain medication. Follow in my office in 7 to
10 days.

Thank you in advance for your help!
 

thomas7331

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I don't think it's the coding that's a problem here. If they are denying this for a medical necessity reason, then it's probably not the coding of the closure of the defect that's at issue and submitting the operative report won't be sufficient. It's more likely that your local Blue Cross probably has a benign skin lesion policy and will only cover the removal of the wart if certain conditions are met. I'd review the policy and then see if there is documentation in the patient's record leading up to the surgery to support that the symptoms that the patient was experiencing, and any conservative measures that were tried and failed, met their requirements for the removal to be necessary. You may be able to appeal with the historical records and/or a letter from the physician showing that this surgery was medically necessary.
 

dncooke03

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In my opinion, I think you just need to use a different primary diagnosis code. The diagnosis code for wart, B07.0, isn’t compatible with CPT 14040 (reread the description of the service). However, you may be able to use it as your secondary diagnosis. The primary diagnosis code should be geared towards the defect that you mention. The closest diagnosis code for the defect, I believe to be, is L98.8.
 

thomas7331

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In my opinion, I think you just need to use a different primary diagnosis code. The diagnosis code for wart, B07.0, isn’t compatible with CPT 14040 (reread the description of the service). However, you may be able to use it as your secondary diagnosis. The primary diagnosis code should be geared towards the defect that you mention. The closest diagnosis code for the defect, I believe to be, is L98.8.
You absolutely cannot code a diagnosis for a defect that was created by the surgeon as part of a procedure - that would be like diagnosing a patient with a laceration to justify a closure due to a surgeon's incision. The operative report clearly states that the diagnosis for this procedure is the wart, and it is not 'incompatible' with the flap code - as the original post points out, correct reporting does not allow the excision procedure to be separately coded.

Keep in mind too that the payer has also reviewed this report and confirmed the medical necessity denial. If you changed the diagnosis code now, then you would really have some explaining to do.
 

dncooke03

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You absolutely cannot code a diagnosis for a defect that was created by the surgeon as part of a procedure - that would be like diagnosing a patient with a laceration to justify a closure due to a surgeon's incision. The operative report clearly states that the diagnosis for this procedure is the wart, and it is not 'incompatible' with the flap code - as the original post points out, correct reporting does not allow the excision procedure to be separately coded.

Keep in mind too that the payer has also reviewed this report and confirmed the medical necessity denial. If you changed the diagnosis code now, then you would really have some explaining to do.
You are absolutely correct! Lesson learned. Thanks for the clarification and correction.
 

ellzeycoding

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In my opinion, this was also an extremely excessive procedure for treatment of a 1cm plantar wart that could have been frozen or burned off.

Carrier denying for medical necessity on something more easily treatable.
 
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