Navigating Lesion and Wound Repair Coding in Dermatology
Are you effectively billing Lesion and Wound Repair procedures in your Dermatology practice? Physicians from various specialties often perform skin procedures, reinforcing the need for accurate coding and complete documentation. Let's look at the coding guidelines as well as the payer requirements for documentation that will assist you in compliantly billing Lesion Excision, Wound Repair, and Adjacent tissue transfers that are common in Dermatology and many other surgical practices.
Lesion Types: Understanding Removal Methods
Various methods exist to remove lesions and to choose the correct code, you will need to understand how they are each performed.
Shaving of Epidermal or Dermal Lesions:
Definition: Sharp removal by transverse incision or horizontal slicing to eliminate epidermal and dermal lesions without a full-thickness dermal excision.
Methods: Includes local anesthesia, chemical, or electrocauterization.
Closure: The wound does not require suture closure.
Excision - Benign Lesions:
Definition: Full-thickness (through the dermis) removal of a lesion, including margins. Involves simple (non-layered) closure when performed. A layered closure beyond the dermis and epidermis top layer of skin can be reported separately as an intermediate repair.
Methods: Requires local anesthesia.
Closure: Simple closure is performed when needed.
Destruction, Benign Lesions:
Definition: Ablation of benign tissues by any method, with or without curettement. Includes local anesthesia and typically does not require closure.
Lesion Excision: Calculate Accurately
Now that we have identified different ways a lesion can be removed, we will look at the excision coding specifically, as it has many layers to reporting it so to speak.
Pre-Excision Measurements: Surgeons should obtain exact measurements at the time of excision with documentation of the margins. Per AMA CPT® “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)” This is done before sending it to pathology, considering potential sample shrinkage.
Benign vs. Malignant: Coding will change based on the morphology of the lesion. You will need to wait for pathology to identify if the lesion was benign (11400-11446) or malignant (11600-11646) to code correctly.
Site Precision: Each lesion can be coded separately based on its site and grouping of that site by code range such as 11440-11446 indicating the lesion will be located in one of the following locations: face, ears, eyelids, nose, lips, mucous membrane
Size Calculation: You should calculate the excised diameter, factoring in margins on both sides, to determine the correct code for each lesion. Then once you identify the anatomical location, you will choose the code that identifies the correct size groupings as well. For instance, for a 2 cm lesion of the ear, you will choose 11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm
Closing the Defect
When a defect is created after removing a lesion, there are various rules to report a repair or closure separately after the lesion excision. We will next review the guidelines for closing the gap in wound repair, offering range-specific instructions for practitioners and coders. The guidelines encompass three key sections: Summing of lengths of repairs for each group of anatomic sites, definitions of each type of closure, and additional scenarios to consider that affect the code selection.
Adding up Repairs for Anatomic Sites: To determine the appropriate code descriptor, coders must be able to see in the documentation the length of the repairs for each anatomic site group. The lengths of repairs should be measured and recorded in centimeters, considering the classification of wounds into Simple, Intermediate, or Complex repairs.
The guidelines categorize wound repair into Simple, Intermediate, and Complex, based on the extent and depth of tissue involvement.
Simple repair is for superficial wounds
Intermediate involves layered closure beyond the first layer of skin (dermis, epidermis)
Complex repairs include exposure of deeper structures or extensive undermining.
Instructions for Listing Services: Coders are guided on how to list services during wound repair, emphasizing the importance of measuring and reporting wound lengths accurately. Additionally, the guidelines in CPT® instruct on the classification of repairs, the use of modifier 59 for multiple classifications, and the handling of debridement as a separate procedure.
Now let’s look at more complex procedures where the combination of the above code sets are inlusive.
Reporting Adjacent Tissue Transfers
Adjacent tissue transfer is a surgical technique that involves taking tissue from an area near the defect or where you excised a lesion and transferring it to cover the damaged or removed tissue.
The transferred tissue may include skin, fat, muscle, or a combination of these components. The primary goal is to use tissue from nearby areas to ensure a good blood supply and promote successful healing and integration of the transplanted tissue. This technique is especially useful when direct closure is not feasible or would result in undesirable cosmetic or functional outcomes.
For coding purposes, adjacent tissue transfer procedures are reported with certain code ranges (e.g., 14000-14302).
For cases involving excision and repair through adjacent tissue transfer or rearrangement techniques, such as Z-plasty, W-plasty, V-Y plasty, rotation flap, random island flap, and advancement flap, the excision of benign or malignant lesions (codes 11400-11646) should not be separately reported with codes 14000-14302.
Instructions:
Full Thickness Repair of Lip or Eyelid:
Refer to the respective anatomical subsections for comprehensive guidance on full-thickness repair.
Codes 14000-14302 Usage:
Apply these codes for excision and repair involving adjacent tissue transfer or rearrangement techniques.
Procedures include Z-plasty, W-plasty, V-Y plasty, rotation flap, random island flap, and advancement flap.
Ensure that these procedures are performed by the surgeon for repair and not for direct closure or rearrangement due to traumatic wounds.
Undermining and Complex Repair:
Recognize that undermining alone for closure, without additional incisions, does not constitute adjacent tissue transfer.
Use complex repair codes (13100-13160) for cases involving undermining without additional incisions.
Lesion Excision:
You cannot separately report codes for the excision of benign (11400-11446) or malignant (11600-11646) lesions when repairing a defect by adjacent tissue transfer as the codes for 14000-14302 include this procedure.
Skin Graft as Additional Procedure:
You can report skin grafts to close secondary defects as an additional procedure.
Include both primary and secondary defects in the measurement for accurate code selection.
Documentation Reminder: Look to the Payer for Guidance
The CMS LCD policy for Removal of Benign Skin Lesions L34938 is important to review as it gives great insight for physicians on documentation requirements as well as the proper ICD10-CM codes that will justify medical necessity. For the aforementioned LCD L34938, there is a corresponding coding article A57113 to review.
Always reference guidelines, insurance coverage, and educate physicians for proper coding and documentation.
For specialized coding reviews, contact coding@healthcareinspiredllc.com
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