Physicians and coders should remember that in most cases, lesion excision will include closure, depending on the necessary level of repair.
Excision CPT codes 11400-11446 (benign) and CPT codes 11600-11646 (malignant) describe the full thickness lesion removal with margins, and include simple closures (non-layered, CPT codes 12001-12018). Repairs by an intermediate or complex closure should be reported separately.
Medicare payers observe strict guidelines: Specifically, CCI edits bundle intermediate (12031-12-57) and complex (12100-12153) repairs to excision of benign lesions of 0.5 cm or less and (11400, 11420, & 11440) – presumably because even complex repairs of such a small wound does not increase surgeon effort appreciably.
Medicare does not bundle intermediate and complex repairs of malignant lesions of 0.5 cm or less.
Example: A surgeon removes three lesions (0.5 cm, benign with complex repair, 0.5 cm, malignant with complex repair, and 2.0 cm, benign with complex repair) from a Medicare patient. You cannot bill a separate closure for the first lesion because it is 0.5 cm or less. You can bill a separate closure for the second excision, even though it is 0.5 cm or less, because it is malignant. And you can bill a complex repair separately with the final excision because the benign lesion measures greater than 0.5 cm.
When determining the length of the incision with the margins, base the measurements on the lesion’s actual size before the surgeon performs the excision and prior to sending it to pathology, not according to the size of the surgical wound left behind.
Each lesion excision should be treated as an individual and separate procedure. Each CPT code billed should have a verifiable diagnosis code when reporting multiple excisions. In addition, you would append modifier 59 (Distinct procedural services) to the second and subsequent codes describing excisions at the same location to avoid duplicate denials.
When reporting wound repairs, remember to add together the lengths of repairs at each identical level of severity and classified anatomic location to arrive at a total length. CPT allows all wounds at the same level of severity and anatomic sub-category as a single, “cumulative” wound.
Laceration repairs have a global period of zero to 10 days, and any follow-up care within the global period cannot be billed. Any new conditions such as an infection, may be billed separately.
Remember that by billing the accurate CPT code(s) this will eliminate unnecessary denials and ensure accurate reimbursement.
For a printable version, click: CCNewsletterMay2008
If you need any additional information on this article or Coding & Compliance services please contact Cindy Tipton at Cindy_Tipton@MED3000.com
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