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Lesion & Closure Question (Newbie)

  1. Default Lesion & Closure Question (Newbie)
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    Hello all, I'm excited to be a part of such a big and diverse group of people!

    My coding scenario is as follows:

    Patient had 3 melanoma lesions removed. 1 face & 1 neck, both about 2 cm in length plus a 2 cm margin. They were removed and placed in fixation for biopsy in separate specimen containers labeled accordingly. Lesion on arm was 4 cm plus a 3 cm margin also removed and placed in fixation and labeled as well. Patient was instructed how to care for the wounds and has a follow up to get biopsy results in about a week.

    According to my text and I also agree that the correct excision codes are:

    11606 for the arm lesion
    11624-59 for the neck
    11644-59 for the face

    Now, for the closure since nothing is stated in the procedure description how do I know if it is simple, intermediate, or complex?

    I'm asking because as presented, I thought it would be a simple closure and included in the excision codes. There is nothing mentioned at all about it and nothing saying anything about it being layered.

    My textbook is saying that they are intermediate closures. What I want to know is how would a person know that without documentation?

    Kind regards,

    Christy

  2. #2
    Default
    you can not code what is not documented. You may querie the physician about the closure method not being documented and have him amend the note to include the closure procedures. Simple is included and intermediate is separately billable but if it is not documented you can not assume what was done.
    Hope this helps.
    Debbie Potts England
    Lyles, TN 37098

  3. Default
    Debbie,

    Thank you very much for confirming my thoughts about this. So in this case the textbook is incorrect. I asked here because I inquired about this from my instructor and the reply she gave me was not one I was comfortable with.

    Christy

  4. #4
    Default
    I work for plastic surgeons and we do a lot of malignant skin lesions and closures. I would say 95% of these closures are complex in nature which my docs document so I agree you need to query your doctor. Since it is melanoma I am guessing it was a deep removal and a complex closure

  5. #5
    Location
    Des Moines, IA
    Posts
    50
    Default
    I also agree that can't code for additional closure without the documentation.

    Also I wanted to point out that it's not necessary to use the modifier 59 on the other two procedures as they are different body areas which is in the cpt descriptions.

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default Classroom problem
    If I understand the original poster ... this is a classroom exercise/problem. She cannot query the provider.

    I agree that there is no documentation of intermediate or complex closure, so that can't be coded.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. Default
    Quote Originally Posted by FTessaBartels View Post
    If I understand the original poster ... this is a classroom exercise/problem. She cannot query the provider.

    I agree that there is no documentation of intermediate or complex closure, so that can't be coded.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Tessa,

    Yes you are correct, it was a sample problem in my textbook. So yes, no one to query. Thank you very much for confirming.

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