Incident-To Billing for Medicare

Question:

I was told for our Medicare patients in order for my PA to report incident-to the physician, that the supervising physician must be in the office.  Is that correct?  We are billing new and established patients under a physician’s NPI number even if there is no physician in the office.

Answer:

To bill Incident-to services a physician must be in the office suite, but it does not need to be the Advanced Practice Provider’s (APPs) supervisor. In addition, you cannot bill incident-to for a new patient when the APP sees them. “Incident To” can only occur for an established patient with an established plan of care originally developed by a physician. If the plan of care changes or the patient has a new or worsening problem, it must be billed under the APP's NPI number. For Medicare, when billing under the APPs NPI number 85% is paid under the Medicare Physician Fee Schedule.

*This response is based on the best information available as of 6/05/25.

Billing for a Simple Repair of the Scalp

Question:

My physician is billing a simple repair of the scalp with CPT code 12001 when he uses steri-strips to do the repair. I don’t believe this is correct. Can we report the use of steri-strips alone to report a simple repair?

Answer:

According to CPT guidelines, repairs are reported when the provider utilizes sutures, staples, or tissue adhesives either singly or in combination with each other, or in combination with adhesive strips. Repairs utilizing adhesive strips alone are not separately reportable. They are part of the E/M service.

*This response is based on the best information available as of 5/22/25.

Need Help Coding Two Dermatology Procedures on the Same Date

Question:

The dermatologist saw a patient in the office yesterday and brought in her pathology report from the family practice doctor. It confirms the cheek lesion is malignant. The physician excised the 1.0 cm cheek lesion and did a simple repair. He also destroyed 3 inflamed seborrheic keratosis with liquid nitrogen on the left hand. What CPT codes should I use?

Answer:

For the 1.0 cm malignant cheek lesion you should report 11641 (excision of malignant skin lesions on the face, ears, eyelids, nose, or lips, with the lesion size ranging from 0.6 to 1.0 centimeters). The simple repair is included in the lesion excision.

For the inflamed SK, you should report 17110 (Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). You will also need to append Modifier 59 to the destruction code (17110) since it is bundled under the National Correct Coding Initiative (NCCI).

Since the lesion excision is on the cheek and the SKs are on the left hand, the definition of Modifier 59 is met as a separate anatomic area. CPT code 11641 has the higher work RVU’s and should be reported without Modifier 59. CPT 17110 should be reported with Modifier 59.

*This response is based on the best information available as of 5/8/25.

Soft Tissue Tumors

Question:

My physician told me to use CPT code 21011 for an excision of a 1.2 cm cutaneous basal cell carcinoma on the scalp. Is this correct?

Answer:

This is a great question. You only use soft tissue tumor codes for the excision of non-cutaneous origin tumors such as lipomas, sarcomas, and hemangiomas. For cutaneous lesions such as basal cell carcinoma 1.2 cm, you would report 11622 (excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). For any excision of a cutaneous lesion, they are reported as malignant excisions (116xx) based on anatomic area and cm size.

*This response is based on the best information available as of 4/24/25.

First Visit for a Chronic Condition

Question:

I am seeing a patient for the first time in the office and they are reporting to me that they have had psoriasis for over two years and their symptoms are worsening; is this problem a level 3 (99203) or 4 (99204)?

Answer:

If your documentation indicates the patient has a chronic condition that is worsening, then the complexity of the problem addressed is moderate, even if this is their first visit to you. However, keep in mind there are three elements to Medical Decision Making:

• Complexity of Problem(s) Addressed

• Amount and/or Complexity of Data to be Reviewed or Analyzed

• Risk of Mortality and/or Morbidity of Patient Management

Two of the three elements on the risk table must be met.  For example, if the condition managed is chronic psoriasis worsening and you write a prescription for a topical medication, the complexity of the problem addressed is moderate with moderate risk. This would indicate a level four new patient visit (99204).

*This response is based on the best information available as of 4/10/25.

Destruction of Seborrheic Keratosis

Question:

I have a patient encounter. I need to code for a patient with 3 SK’s, 2 on the right forearm and 1 on the left forearm. The physician froze the lesions. I am thinking I should code 17000 x 1 and 17003 x 2. Is this correct?

Answer:

The correct CPT code to report for destruction of SK’s is 17110 (destruction benign lesions other than skin tags or cutaneous vascular proliferative lesions up to 14). You will only report CPT code 17110 with 1 unit since the code includes 1-14 lesions. CPT codes 17000-17004 is used to report the destruction of premalignant lesions for example an AK (actinic keratosis).

*This response is based on the best information available as of 3/27/25.