Dermatology Procedure Coding

Dermatology Procedure Coding

Anatomy Two layers that make up human skin Epidermis most superficial layer Composed of four to five layers called stratum Anyone remember the mnemonic? Thickness varies based on location of layer

Anatomy Dermis located under epidermis Average thickness is 1mm 2mm Three types of tissues found Contains structures often referred to as skin appendages

Anatomy Subcutaneous tissue used synonymously with hypodermis and not considered a layer of skin

Documentation ICD-10 Codes Submit codes with highest degree of accuracy and specificity CPT Codes Review codes to ensure diagnosis supports medical necessity for the procedure performed

Documentation Lesions Documentation must include Size, location, number of lesions removed If pathology report states lesion of uncertain morphology Choose accurate CPT code that relates to final diagnosis in pathology report

Specific Procedures

Incision and Drainage 10060 - Incision and drainage of abscess (e.g. carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single 10061 - Complicated or multiple

Skin Tags 11200 - Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions +11201 - each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) Guideline: Removal with scissors or any other method including electrosurgical destruction or combination, including chemical or electrocauterization, with or without local anesthetic

Intralesional Injection Codes 11900 - Injection, intralesional; up to and including 7 lesions 11901 - More than 7 lesions Stand alone codes Not used for local anesthetic Report both procedure and drug Example: Keloid injection with Kenalog

Biopsy 11100 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure) unless otherwise listed; single lesion + 11101 - Each separate/additional lesion (List separately in addition to code for procedure)

Biopsy No global days You can bill for follow-up visits Assumes you are submitting tissue for pathologic examination

Shave Biopsies Sharp removal by transverse incision or horizontal slicing No global days You can bill for follow-up visits NOT full thickness, dermal excision No sutures required Codes based on anatomic location and size 11300-11303: Trunk, arms, or legs 11305-11306: Scalp, neck, hands, feet, genitalia 11310-11313: Face, ears, eyelids, nose, lips, mucous membrane

Excision Codes Global period Typically 10 days can t bill separately for suture removal/follow-up during that time frame Full thickness, through dermis with removal of lesion Includes simple (non-layered) closure Reported based on Anatomic area Size of excised diameter (NOT THE LENGTH OF REPAIR) Malignant or benign (often have to wait for pathology to return before submitting charges) 114xx Benign 116xx - Malignant If more than one lesion is excised, each lesion should be reported separately

Excision Codes - Pearls Billed based on largest diameter of lesion plus narrowest lateral margins Examples How would you bill a round 4mm lesion placed centrally in 8mm punch? 8mm: 4mm (lesion)+2mm (one narrowest margin)+2mm (other narrowest margin) How would you bill an ovoid 8mm x 4mm lesion removed with 2mm margins around the widest portion of lesion with an elliptical excision? 1.2cm: 8mm (lesion)+2mm (narrowest margins counted twice)

Excision Codes - Pearls Measure first, Cut Second! Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus the most narrow margin required for complete excision. Measure the lesion and margins prior to excision as the lesion will shrink as soon as the incision releases the tension on the skin Formalin shrinks tissue too

Re-excision Pearls A procedure on any lesion previous biopsied or undergone an initial excision by you or anyone else Use total closed length of excision to guide code selection If re-excision shows no residual malignancy, should still bill the malignant lesion diagnosis codes because that was the purpose of the reexcision

ICD-10 Codes Signs and symptoms codes acceptable when no definitive diagnosis available from which to code R20.8 Other disturbances of skin sensation (use to indicate irritated lesions)

Neoplasm Uncertain/Unspecified D48.5 Neoplasm uncertain behavior Dysplastic nevus Keratoacanthoma Lesion pending more work-up (histopathology) D49.2 Neoplasm unspecified behavior of bone, soft tissue, and skin Based on documentation in the medical record

Site Specific ICD-10 C43.x Malignant Melanoma D03.xx Melanoma in situ 5 th digit: 1 = R, 2 = L C44.xx Malignant Neoplasm 5 th digit: 1 = basal cell 5 th digit: 2 = squamous cell D23.x Benign Neoplasm.0 lip.1 eyelid.2 ear.3 face (other).4 scalp, neck.5 trunk.6 upper limb.7 lower limb.8 other sites D04.x Carcinoma In Situ

ICD10 Neoplasm Instructions Primary malignancy previously excised once a malignant lesion has been removed with no evidence of recurrence or need of further treatment, the patient s condition will be considered a personal history of a neoplasm (Z85.82x) Z85.820 Personal Hx of melanoma Z85.828 Personal Hx of other malignant neoplasm of skin

Biopsy vs Shave vs Excision Pearls Excision Intends to fully remove a lesion and must be full thickness Biopsy Samples anything less than full lesion, even if full thickness Shave Use if intending to remove entire lesion by anything less than full thickness

Cases 4mm suspected nodular BCC removed with 8mm punch (2mm margins) and sutured Biopsy or Excision? Excision 1cm suspected SCC sampled full thickness into SC fat with 4mm punch centrally Biopsy or Excision? Biopsy 6mm suspected melanoma completely removed with Dermablade saucerization extending into deep dermis Shave or Excision? Shave

Biopsy vs Shave If sampling dermatitis (eg suspected psoriasis) specimens should be classified as biopsies even if lesions are entirely removed using shave technique Bill using ICD-10 L98.9 (unspecified disorder of skin/sc tissue) If bill using code for psoriasis, insurer may reject claim and ask why biopsied if dx known

Seborrheic Keratosis Removal Pearls If known or suspected SK, needs to be symptomatic in order to be reimbursed for removal Shave only Inappropriate to excise suspected SK If can t determine SK vs melanoma, acceptable to do a full thickness removal and bill for excision

Don t Submit Claims Prematurely Excision codes and payments differ depending on pathologic returns benign or malignant Biopsies and shaves should be coded and billed immediately No difference whether benign or malignant Equivocal pathology (eg atypical or dysplastic nevus) should be billed using benign codes

Uncertain Lesion Removal Pearls Example: Single papulosquamous plaque Differential: SCC, BCC Lesion removed completely with shave and billed with appropriate shave CPT code and ICD-10 code D48.5 (neoplasm of uncertain behavior of skin) Pathology returns psoriasis Must you rebill using biopsy code? No! Intent was to evaluate for suspected malignancy. Make sure documentation notes differential!

Destruction of Lesions 1700x Premalignant 1711x Benign Any method Number treated 1726x Malignant Based on anatomic location and excised diameter Any method Laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement

Destruction of Lesions Benign Lesions ICD-10 Codes B07.9 (Viral warts) L82.0 (Inflamed seborrheic keratosis) CPT Codes 17110 Up to 14 17111 15+ Premalignant Lesions ICD-9 Codes L57.0 (Actinic keratosis) ONLY CPT Codes 17000 1 lesion +17003 2 nd thru 14 th lesions (each) 17004 15 or more lesions

Destruction of Lesions Malignant Coded by anatomic location and size 1726x: Trunk, arms, legs 1727x: Scalp, neck, hands, feet, genitalia 1728x: Face, ears, eyelids, nose, lips, mucous membrane

Destruction of Lesion Pearls Don t upcode destruction of benign lesions or undercode destruction of malignancies Even if deep plantar warts or superficial molluscum require local anesthesia and curettement/shaving, still should only bill 17110 or 17111 depending on number Billing should be based on what is medically necessary (these are epidermal lesions) Provider billed $7K for shaving multiple molluscum and was audited

Destruction of Lesion Pearls When dealing with malignancy curable by cryotherapy alone or curetage +/- EDC, procedure often starts with shave followed by destructive procedure Can only bill for one procedure Codes for destruction malignancies pay more than those for shaves Example Average reimbursement destroying 2.5 cm malignant scalp lesion (17273): $208.31 Average reimbursement for shave same lesion (11308):$123.90

Coding Wound Repair Add all lengths of repairs in the same code classification (anatomic area and technique) Sum of length of repair reported as a single code Example: Simple repair trunk (o.3 cm), scalp (0.2 cm), axillae (0.5 cm) You report 0.3 + 0.2 + 0.5 = 1 cm

Simple Repairs CPT Codes 12001 12018 Usually included in all minor and major surgical procedures Cannot be reported separately when performed in conjunction with minor/major procedure However, can be reported if that is the only service provided e.g. simple closure of laceration

Intermediate Repairs (12001-12057) Use for repair of wounds or defects which: Require layered closure, one/more deeper layers SC tissue and superficial (nonmuscle) fascia Need prolonged support to control tension Need obliteration of dead space Guidelines: Code by site and length (sum of lengths Report IN ADDITION to excision code NOTE: Not appropriate to be used with excision of benign lesions 0.5 cm or less

E/M Bundling Issues When an E/M service is provided and represents a separately identifiable service, it is reasonable for physicians to expect payment, assuming that the physician has documented a separate E/M service in the medical record. It is generally more convenient for the patient and more cost effective if multiple separate services can be provided on the same date rather than requiring multiple return visits. The -25 modifier is the most straightforward way for physicians to indicate a separate E/M service to carriers, and the CPT descriptor of modifier -25 is clear enough that it should not be misconstrued by carriers. Carriers are expected to recognize modifiers. The CPT definition of modifier -25 states that an E/M service may be prompted by the system or condition for which a separate procedure or service is needed, and as such, different diagnoses are not required for the E/M service and other separate procedure.

Modifier -25 FAQs True or False: E/M with Modifier 25 should be used every time a patient comes to the office and has a procedure FALSE Every procedure has some elements of E/M included. Taking vitals and a brief history/exam is part of the procedure. The E/M service must be significant, above and beyond the care that is normally associated with the procedure.

Modifier -25 example If the patient has already been worked up at a previous visit and is returning for a scheduled procedure, It may not be necessary to perform another E/M service above and beyond the normal care associated with the procedure. If the procedure was not planned ahead of time and it is medically necessary to perform an E/M service, it may be reported separately with modifier -25.

Other Pearls

Know When to Bill the Patient Rather Than the Insurer If lesions asked to be removed for cosmetic reasons, most insurances won t pay. Billing insurance for cosmetic removal may be deemed fraudulent. Patient needs to sign ABN (especially for Medicare) If benign lesions (skin tags, SK) are symptomatic (irritated due to catching on clothing or brushes), remove and bill insurance Include code R20.8 (disturbance of skin sensation) to ICD-10 for skin tag to denote irritation

Send Everything for Histopathology Protects you if you ever removed anything and patient develops melanoma at a later date Possible exceptions Skin tags that are soft and absolutely typical Typical verrucae in younger patients

Know When to Use Multiple Codes Or a Single Code for Multiple Lesions Treating or destroying multiple benign lesions (eg warts) of same type Doesn t matter if you use different methods Shaving, cryotherapy, cantharidin, Candida antigen injection Only matters number of lesions 14 or fewer (17110) 15 or more (17111) Biopsy 3 different lesions or three different areas of a dermatosis Code 11100 for first biopsy +11101 for each additional biopsy (in this example quantity 2) If removing multiple lesions in single visit by shave or full thickness excision, report each separately with modifier -59 to indicate these are distinct procedural services provided on same day

Multiple Surgery Rule The Multiple Surgery Rule as described in the Federal Register, June 24, 1994, p. 32767-32768, is the current standard for multiple procedure payment. This rule bases payment on the lesser of the actual charge or 100 percent of the fee schedule amount for the primary procedure and 50 percent for the second through fifth procedures.

Great Review Article http://www.aafp.org/fpm/2013/0100/p11.html