Gary N. Fox, MD, and Laura A. McCann, CPC, CCS-P Errors to Avoid in 12 Coding Skin Procedures Using the correct codes can mean the difference between getting paid and getting audited. oding and billing for diagnosing and treat- must be full thickness, which means entirely through the ing skin lesions is rife with potential pitfalls reticular dermis to fat. For example, let’s say a lesion that could lead to delayed payments at best appears to be a 4 mm nodular basal cell carcinoma (BCC) and increased insurer scrutiny or investiga- or a nevus. An 8 mm punch is used to excise the vis- tion forC fraud at worst. Because skin procedure codes take ible portion of the lesion with apparent 2 mm margins into account the type of removal, the size and location of in all directions with the punch carried full thickness. the lesion, your intent, and pathologic results, document- The lesion has been excised. The excision code includes ing your service and selecting the right code can be confus- anesthesia and straightforward, simple closure. If the ing. This article explains how to avoid some of the most procedure required extensive undermining, a two-layer common mistakes in skin procedure coding and provides closure, and removal of excess skin, a separate code for a an encounter form that can help you to more rapidly and moderately complex closure should be used. accurately report skin-related diagnoses and associated pro- By contrast, a biopsy is a procedure that samples any- cedures (see the form on page 14). thing less than a full lesion, even if full thickness (“inci- sional” rather than “excisional”). For example, sampling a 1 cm suspected squamous cell carcinoma (SCC) at full thick- Know the difference between an ness into subcutaneous fat with a 4 mm punch instrument excision and a biopsy. 1 centrally should be coded as a biopsy. A biopsy code might An excision is a procedure intended to fully remove a also be used when sampling one or more of a group of lesion. The specimen should include the lesion and the lesions for diagnosis, even if these sample lesions are com- surgical margins. To qualify as an excision, the procedure pletely excised, or when taking samples of a dermatitis. ➤ Downloaded from the Family Practice Management Web site at www.aafp.org/fpm. Copyright © 2012 American Academy of Family Physicians. For the private,January/February noncommercial 2013 use| www.aafp.org/fpm of one individual | FAMILYuser of PRACTICE the Web MANAGEMENTsite. | 11 SERGE BLOCH SERGE All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. WHEN A PATIENT ASKS FOR REMOVAL FOR COSMETIC REASONS, MEDICARE, MEDICAID, AND MOST OTHER INSURANCE PLANS DO NOT COVER THE SERVICE. Complete removal does not necessarily ogy laboratories include that information in mean that an excision code should be used. their reports. When the intent is to entirely remove the A re-excision is a procedure on any lesion pathology by anything less than a full thick- that has been previously biopsied or under- ness technique, a shave code may be appro- gone an initial excision by you or anyone else. priate, even if the pathology report confirms When billing for a re-excision, use the total complete removal of the lesion. For example, closed length of the excision to guide your trying to completely remove a nevus or sus- code selection. When a patient presents for pected melanoma via a “scoop” or “sauceriza- a scheduled re-excision, you should bill for tion” technique that extends into the deep the procedure but not the office visit, unless dermis and not the fat should be coded as a significant, separately identifiable services are shave removal, not an excision. provided, in which case you could submit a Excisions, biopsies, code for the evaluation and management ser- and shaves have vice with modifier 25. Don’t overbill for excisions or their own defini- If re-excision shows no residual malig- underbill for re-excisions. tions and uses. 2 nancy, you should still bill the malignant A primary excision should be billed based on lesion diagnosis codes, because that was the the largest diameter of the lesion plus the nar- purpose of the re-excision. rowest lateral margins. For example, a round Measure lesions 4 mm lesion placed centrally in an 8 mm before removal Know the difference between punch has a lesion diameter of 4 mm and as they tend to 3 biopsy and shave. change shape 2 mm margins all around. The excision length afterward. for this lesion is 8 mm: 4 mm (lesion) plus When there is a dermatitis, such as suspected 2 mm (one narrowest margin) plus 2 mm psoriasis, contact dermatitis, or Grover’s (other narrowest margin). For an ovoid lesion disease, specimens you obtain for pathology measuring 8 mm by 4 mm, removed with 2 should be classified as biopsies even if the sam- Re-excisions don’t mm margins across the short diameter and pled lesions are entirely removed using a shave generate an added greater margins at the apices to fashion a fusi- technique. List your suspected diagnosis in office visit fee. form excision closer to the traditional length- your clinical notes, but you should bill using to-width ratio of 3:1, the calculation would be diagnosis code 709.9 for unspecified disorder 12 mm: 8 mm (lesion) plus 2 mm (narrowest of skin and subcutaneous tissue. If you use margins counted twice) (see the photo illustra- the code for psoriasis, for example, the insurer tion on the next page). may reject the claim and ask why you did a The lesion should be measured preopera- biopsy if you already knew the diagnosis. tively because tissue tends to change shape or If you remove and “cure” a symptomatic shrink in formalin, which causes pathologic seborrheic keratosis via a shave technique, measurement to be generally smaller than the that can be appropriately billed as a shave. If clinical measurement, and some dermapathol- you cannot determine whether a lesion is a seborrheic keratosis or a melanoma and you do a full thickness excision because of concern About the Authors about melanoma, it is legitimate to bill for Dr. Fox is a family physician who has limited his excision. It is almost always inappropriate to practice exclusively to skin diagnosis and treatment excise seborrheic keratoses when you are cer- since 2005 at the Mercy Defiance Clinic in Defiance, tain of the diagnosis. It is often appropriate to Ohio. Laura McCann is the information services remove them because of symptoms, but only director at Mercy Defiance Clinic. Author disclo- via the shave technique. Note that for smaller sure: no relevant financial affiliations disclosed. lesions, biopsy codes may provide greater 12 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | January/February 2013 SKIN PROCEDURES reimbursement than shave codes. mend switching. I have used 238.2 exclusively Lines can be blurred. For example, let’s say for years with good results. a person has a single papulosquamous plaque, and the differential diagnosis includes SCC Don’t upcode destruction of and superficial BCC. An attempt to com- benign lesions or undercode pletely remove the lesion via a shave technique 4 destruction of malignancies. is documented. The histology report indicates Some procedures psoriasis. Because the intent was to evaluate Molluscum and verrucae are epidermal could be billed as biopsies or shaves, for a suspected malignancy and the lesion was lesions. On palms and soles, verrucae can be but the reimburse- completely removed, documentation would very deep and invaginate the epidermis and ment levels are support billing a shave code. A biopsy code even make radiographic impressions on bone. different for each. also would have been appropriate, but the However, even if you inject anesthesia and shave code is legitimate and the reimburse- curette a deep wart on a plantar surface or ment is greater. It is okay to get paid for what use any of a variety of methods of removing you do! molluscum, the appropriate code is either Wart removal is My research suggests that most derma- 17110 (destruction of benign lesions, 14 or most appropri- tologists tend to use the diagnosis code for fewer lesions) or 17111 (15 or more lesions), ately billed using neoplasm of uncertain behavior of skin because the billing should be based on what is destruction codes. (238.2) when biopsying or shaving a lesion of medically necessary. uncertain etiology because of concern about When dealing with a malignancy that is malignancy and billing before the histopathol- curable by cryotherapy alone or by curet- ogy is known. This remains the appropriate tage with or without electrodessication or Bill excisions based code after histology has returned for dysplas- cryotherapy, the procedure often starts with on adding their largest diameter tic nevi, sebaceous nevi, and other lesions of a shave followed by the destructive proce- with their narrowest uncertain biologic behavior. The other option dure. You can only bill for one procedure lateral margins. is to submit the diagnosis code for neoplasm in this case, and the codes for destruction of of uncertain nature (239.2). Some coding malignancies pay more than those for shaves authorities emphatically recommend this code or biopsies. For example, Medicare’s median rather than 238.2, but if you have been using nongeographically adjusted payment rate 238.2 without difficulty I wouldn’t recom- for destroying a 2.5 cm scalp lesion (code HOW TO MEASURE AN EXCISION LENGTH FOR PROPER CODING This macular lesion is suspicious for melanoma. Many authorities recommend a 2 mm margin, full thickness, primary excision for diagnosis and initial pathologic staging to guide subse- quent re-excision and management.