Coding Consult

When you remove a skin lesion

Did you shave it? Excise it? You'll need to use correct terminology before submitting a claim.

Terry Fletcher, CPC

Coding for lesion removals can vex a primary care physician. But many doctors make the subject more complicated than it needs to be.

At a basic level, there are four methods of lesion removal, and you'll need to know which category your service falls into:

1. Biopsy (11100-11101): Removes part of a lesion for testing and diagnosis. Wait for pathology before coding.

2. Shaving (11300-11313): Removes the entire lesion but does not penetrate the underlying fat. Moles are the most common lesion that doctors shave.

3. Excision, benign (11400-11471) or malignant (11600-11646): Removes the entire lesion by cutting through the fat. Generally requires sutures and possibly layered closure.

4. Destruction, benign or premalignant (17000-17250) or malignant (17260-17286): Destroys lesions by laser or liquid nitrogen "cryo," as is done with warts.

It's important to document the type of removal accurately. For example, doctors sometimes confuse medical terms with CPT language. They tend to use "shave biopsy" or "biopsy excision" when documenting their service. For coding purposes, however, the procedure method is either a biopsy or an excision or a shave—don't mix terms. The documentation must include the size of the lesion and whether it was sent for biopsy.

I strongly recommend that you dictate a report when a procedure is performed, instead of just writing it down. That should help smooth the way with the carrier.

Of the four lesion-removal methods, an excision is typically reimbursed the highest, followed by a shave, then biopsy and destruction. Reimbursement is usually at least 30 percent higher for malignant lesion removal than for benign. Read through the sections in the CPT book that cover lesions to get the clear definition on what codes are most appropriate for your situation.

Correct coding also depends on the lesion's size and location. Many physicians guess at the size, which is fine if the guess is well documented in the record. But even 1 centimeter can make a huge difference in your reimbursement. Note that the size is based on the size of the lesion, not the size of the excision.

If a lesion needs to be re-excised, the acceptable standard to calculate size is the width multiplied by 2.5. This determines the length and helps indicate whether a closure was necessary and required sutures.

The codes for closure (12001-13160) can be added to the excision code as long as you document that it was an intermediate or complex closure of a lesion larger than 0.5 centimeter. Medicare rules state that anything smaller may not have a repair code added.

A couple of caveats related to lesion removal:

First, make sure that you don't use lesion-removal codes when removing skin tags, which have their own codes (11200-11201).

Also, Medicare guidelines say that a lesion removal must be both medically necessary and symptomatic in order to be reimbursable. For example, a patient wants a mole removed from her face. It has been there for years and has never changed color. Its removal doesn't qualify as a medical necessity. On the other hand, if the mole is at her panty line and keeps bleeding from clothing irritation, Medicare would consider its removal medically necessary.

You'll need to append modifiers when you remove multiple lesions: –51 (multiple procedures) if there were multiple lesions at the same site; –59 (distinct procedural service, different anatomical site) if, say, you removed lesions from the back and the arm; or –76 (repeat procedure by the same physician) if you needed to re-excise a lesion within a week.

The author, a certified professional coder, is a consultant and seminar leader for McVey Associates (mcveyseminars.com), an insurance reimbursement consulting company in Novato, CA. This department answers common coding questions. Since coding rules frequently change and are subject to interpretation by insurance carriers, decisions should be made in light of individual circumstances, local conditions, payer policies, contracts, and new or pending governmental policies. We welcome your questions for future columns. Please submit them to mecode@medec.com. Sorry, but we're not able to answer readers individually.

Terry Fletcher. Coding Consult: When you remove a skin lesion.

Medical Economics

Dec. 3, 2001;78:16.