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Family Practice Coding Alert

Size, Location, Medical Necessity Affect Lesion Removal Coding

The problem with lesion removal arises when family doctors confuse medical terms with CPT language, says Inga Ellzey, MPA, RRA, AHIMA, AAPC, chief executive officer of the Inga Ellzey Practice Group, a coding consulting firm in Casselberry, FL. They might use a term such as shave biopsy, but it cant be both. Even if a shaved mole is sent to the pathologist, its not a biopsy. Or they use biopsy excision. Its either biopsied or excised, she says.

The removal of lesions, which is a common procedure in family practice offices, triggers questions in several areas:

four different codes depending on how the lesion is removed;

proper measurement of a lesion to ensure apropriate coding;

codes related to re-excisions;

medically unnecessary versus medically necessary
lesion removals; and

coding for the removal of two lesions during one visit.

The four types of removal are:

1. biopsy (11100-11101): the partial removal of a lesion for the purpose of diagnosis. If a lesion goes to pathology, dont code until the results are back,
suggests Ronni Collins, CPC, a coding consultant with Berkeley Family Practice in Moncks Corner, NC, which has two physicians and three physician assistants. If the lesion is malignant, you can get a higher reimbursement.

2. shaving (11300*-11313): removes the entire lesion but does not penetrate through to the fat. Moles are the most common lesions to be shaved.

3. destruction (17000*-17250*, benign; 17260*-17286, malignant): lesions are usually destroyed by liquid nitrogen, laser or burning, as with warts.

4. excision (11400-11471, benign; 11600-11646, malignant): cuts are made through to the fat to remove the entire lesion. They generally require sutures.

James A. Zalla, MD, a dermatologist with Dermatology Associates of Northern Kentucky in Florence, chairman of the Academy of Dermatologys classification and coding task force, and a member of the CPT education panel, says to use caution and make sure you use the shave removal code when the incision does not go through to the fat and the code for excision if it does.

The type of removal has to be reflected in documentation, so not only do physicians have to choose the correct code, they also have to provide documentation to support it, Ellzey says. The four types warrant different levels of reimbursement, with excision being the highest, followed by most shaved lesions, then biopsy and destruction.

Size Does Makes a Difference

The coding for shaving, destruction and excision depends on the size and location of the lesion. Ellzey says many physicians just eyeball the size of a lesion, but even one millimeter can change the code and your reimbursement amount. She explains that the size is determined by the biggest of the measurements for [...]