Measurements for Excision of Lesion Removal

Question:

Our coder sometimes uses measurements listed in the pathology report for lesion excisions, because the measurements are unclear or missing in the procedure note. Is this ok?

Answer:

No, for several reasons. Once removed, tissue(s) shrink so don’t depend on the measurements listed in the pathology report as it will most likely be smaller than the actual excision. And It is always necessary to have the measurements of the excision documented in the procedure note. So, if you have Question:s or need documentation clarification, ask your provider for help so he/she can amend the note prior to billing if necessary.

Excision means lesion plus margins (the narrowest margin), not just lesion itself. CPT 2019 gives us several illustrations on page 83 of how to calculate for these codes, so make sure to share this information with your coder and provider.

*This response is based on the best information available as of 12/19/19.

Definition of Simple versus Complicated

Question:

What is the definition of simple vs complicated for the I&D codes 10060 versus 10061?

Answer:

While CPT doesn’t define the difference between “simple” and “complicated”, it is the accepted practice that a simple I&D 10060 is just that. An incision (not just a puncture) is performed, and the abscess is left open to drain and heal. A complicated I&D 10061 would usually require one or more of the following: multiple incisions, probing to break up loculations, extensive packing, drain placements, and wound closure. If documentation isn’t clear on what exactly was performed, ask the provider for guidance as the reimbursement difference with these codes is fairly significant.

*This response is based on the best information available as of 11/14/19.

What Constitutes the Trunk for Complex Repairs?

Question:

CPT question for anatomy: When coding complex repairs CPT 13100-13102 for complex repair of trunk. What body area is included in the “Trunk”.  For simple and intermediate repairs the trunk is included with the scalp, extremities, neck, axillae and trunk.

Answer:

You can determine the answer by looking at the code descriptors for the other complex repair anatomic groupings. CPT codes 1312-13122 include the scalp, arms, and/or legs; CPT codes 13131-13133 include the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet. Therefore, 13100-13102 is specifically just the trunk – chest, abdomen, and back.

*This response is based on the best information available as of 10/17/19.

Lesion Excision and Repair

Question:

I saw a patient for an excision of a squamous cell carcinoma on his chest. The size is 4.2 cm diameter. I know I report 11606 for the lesion excision but I also did an intermediate repair with a layered closure and the side is 6.5cm. Can I bill for the repair or is it included? My coder says it is billable with Modifier 59. Can you provide some guidance?

Answer:

You are correct that you report CPT code 11606 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm) for the excision. Yes you can report the repair based on CM size which would be coded with CPT code 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm). You would not append Modifier 59 since it is not a bundled service. The correct modifier to use is 51 and append it to the lesser RVU procedure which is the repair.

*This response is based on the best information available as of 07/25/19.

Ear Biopsy

Question:

What is the correct code for a tangential biopsy of the antihelical fold?  I was going to bill 11102, but I was told that there are different codes in other sections of CPT for some biopsies.

Answer:

The correct code would be 69100,Biopsy external ear.  As a bonus, this correct code would reimburse at a higher level than 11102.  According to the Medicare fee schedule, the national reimbursement rate for 11102 is $41.08 and for 69100 it is $50.45.

*This response is based on the best information available as of 5/23/19.

Pilonidal Cyst Removal and Repair

Question:

If one of our doctors removes a complex pilonidal cyst that requires a rhomboid flap repair, is the repair part of the code 11772 for complicated excision of the pilonidal cyst?  I did not think so, but I know that each procedure includes the approach, the definitive, and closure, so now I am not sure.

Answer:

A flap closure is separately reportable with an excision of a pilonidal cyst.  In this case, you would also report a code from the adjacent tissue transfer section, 14000-14302, depending on the site and square centimeter sizes of the primary and secondary defects.

*This response is based on the best information available as of 2/14/19.