Excisional Biopsy

Question:

My physician is insisting that I bill an excision biopsy using a punch as a punch biopsy (11104). The documentation says the lesion was removed in its entirety. Is this a biopsy of lesion excision. She does not document the cm size of the removal.

Answer:

Skin biopsy procedures can be grouped by how much of the lesion is removed. If you have an excisional biopsy, the entire lesion is removed. Examples of excisional biopsy procedures include elliptical excision, deep scoop shave, and punch biopsy for small lesions. Codes should be reported with the excision codes 11400-11471 (benign lesions) or 11600-11646 (malignant lesions). The practice should wait for the pathology report for correct coding. The physician should document the anatomic location, method of removal and cm size at a minimum.

Cleft Lip Repair

Question:

What CPT code do I use to report the repair of the cleft lip with a cross lip pedicle flap and sectioning and inserting the pedicle? I was told to report CPT 40527

Answer:

The correct code to report is 40761. CPT 40527 does not include sectioning and inserting the pedicle.

Soft Tissue Tumor Excisions

Question:

My physician performed two soft tissue tumor excisions in different areas on the scalp. They measured 1.0 cm and 1.5 cm. Can I bill for both? Also can I report a layered closure.

Answer:

You would report CPT 21011 (excision soft tissue tumor, scalp 2cm or less) for the first excision and 21011-59. Modifier 59 is used to indicate a completely separate procedure was performed using the same CPT code to avoid a claim denial for “duplicate charge. The repair is included in the global package for the excisions and not separately reported.

Foreign Body Versus Implant

Question:

What is the difference between an implant and a foreign body?

Answer:

On page 90 of the Current Procedural Terminology (CPT) Professional Edition 2022, the definition was added to the guidelines. “An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is that the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices
What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:
The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in the Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period instead, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.