C PT rules aren’t easy. Many codes have nebulous descriptors while others have almost no guidelines at all. Sometimes the way a code should be used in the real world isn’t defined very well in the CPT book at all. One of the most commonly misunderstood sections of the Integumentary System (e.g., CPT codes 10000 to 19999) involves the use of the excision codes (CPT codes 11400 to 11646) and the use of intermediate and complex repairs (CPT codes 12031 to 12057, and 13100 to 13153 respectively). In this article, I’ll answer some questions that I get asked over and over again. Many of the questions have to do with adding. You’ll see what I mean as you read continue reading. Q: I frequently see patients who present with multiple nevi that need to be sent for pathologic review. Often, I’ll see two moles in very close proximity to one another that need to be excised. When I excise lesions that are so close, I can usually remove both lesions with one ellipse. For example, I may have two moles — one 4 mm/d and one 5 mm/d. In a case such as this, I would remove both with one ellipse. My question regarding this practice is three-fold: 1. Can I bill one excision for the 4-mm nevus and one excision for the 5-mm nevus, or must I add them together and bill only one excision? 2. If I can bill both separately, how do I measure their size since I need this information in order to comply with the new method for billing excisions that requires calculating the size of the actual lesions and adding that to the size of the conservative margins? 3. If I can bill both separately, do I need any modifiers? A: I’ll answer these questions in the order they were asked. 1. Bill each one separately. Excisions are never added together regardless of whether you excise them both in one ellipse or if you excise each one separately. 2. How you determine your measurements depends on how you orient your ellipse. Let’s look at this in two ways: a. Let’s assume that both lesions (located on the patient’s back) are side by side so the width of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each side. Let’s also assume that there was 1 mm between the two lesions and that you took 2-mm margins on the left and right side of the ellipse. So you add (from left to right): 2 + 4 + 1 + 5 + 2 = 14 millimeters or 1.4 centimeters. This measurement represents the width of your ellipse. To get an excised diameter for each lesion, I would take the area between the lesions and divide it in half giving you a 0.5-mm measurement. I would then measure the size of the nevus (4 mm) and the outer margins (2 mm). Add these together with the 0.5 mm and you get your first size; a lesion with an excised diameter of 6.5 mm or 0.65 centimeters. You do the same for the 5-mm lesion. Take 0.5 mm, which represents half of the area between the two lesions, add the lesions size of 5 mm and then add the outer margin of 2 mm. This gives you a lesion with an excised diameter of 7.5 mm or 0.75 cm. Assuming that both lesions are benign, you would bill using CPT codes 11401 and 11401. Let’s also assume that the length of your ellipse was 3.5 centimeters. Based on the type of closure you selected (either an intermediate repair or a complex repair), you bill for the repair using only one repair code. Repairs of the same anatomical classification are always added together. So let’s assume that you did an intermediate repair. You use CPT code 12032 based on a 3.5-cm long defect. b. Let’s assume that both lesions of the back are vertical (one above the other) so the length of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each end of the length of the ellipse. You would use the same measurement process as outlined in example A for determining the excised diameter of each lesion. To determine the length of the ellipse (the size used to select the repair code, if appropriate) assume that there was 1 mm between the two lesions and that you took 3-mm margins on each end of ellipse. So you add (from top to bottom): 3 + 4 + 1 + 5 + 3 = 16 millimeters or 1.6 centimeters. This measurement represents the length of your ellipse. If an intermediate repair was performed, you would bill using CPT code 12031. 3.Yes, you need a modifier in both examples “A” and “B” because you have two CPT codes that are identical. You bill: Example “A” 11401 11401 -76 (or -59 depending on carrier preference) 12032 Example “B” 11401 11401 -76 (or -59 depending on carrier preference) 12031 If the excisions had different CPT codes, such as 11401 and 11402, you would not need any modifiers: 11401 11402 12031 (or 12032) Q: I am always confused about how you know which repairs are added together and which are not. For example, I repair two defects resulting from two excisions. They are both on the trunk, but I close one with an intermediate repair and the other with a complex repair. Must I add the two repairs together and only bill one CPT code since they are both on the trunk? Or, can I bill them separately because they are closed with two different types of techniques; one being an intermediate closure while the other is complex? A: First, the answer is “no”. You do not add together the length of repairs if you are closing defects with different types of closures. You only add together lengths that are: 1. in the same anatomical classification (I’ll discuss this more later). 2. repaired with the same type of repair technique (intermediate or complex). Second, you need to understand the classifications as they are defined by CPT. Classifications refer to anatomical body areas such as trunk, extremities, axillae, scalp, neck, hands, feet, external genitalia, face, ears, eyelids, nose, and lips that are lumped together under one CPT code. (Keep in mind that the size is also a determining factor in code selection.) If two repairs are performed by the same technique (intermediate repair, for example) and are located in the same anatomical classification, then you add together the length of the repairs and bill the one CPT code that represents the sum of the two lengths. Read the charts carefully. The classifications are different for the two types of repairs: intermediate versus complex. For example, layer closure of the scalp, axillae, trunk, and extremities is one classification whereas under the complex repair codes, the trunk is one classification, while the scalp, arms and legs are a separate classification. On the next page are two charts that show the CPT codes and their anatomical classifications. Next, let’s review the classification blocks. The rule is simple: You can never bill more than one code from any one block on the same date of service for the same patient. Q: I’m a Mohs surgeon, and I’d like to know what to do in the following scenario. If I use two different types of flaps (e.g., adjacent tissue transfers), do I add together the sum of the two flaps or can I bill each flap separately? A: Flaps are not added together if two different types of flaps are needed to accomplish one repair. Check for the use of modifiers as some of these codes may be bundled. If they are bundled, you attach modifier -59 to the bundled service since the definition of modifier -59 includes “different procedure”. Q: If a repair cannot be closed by a flap alone, but also requires a complex repair, can both be billed? A: That depends on the CPT codes you wish to bill. In some cases you can bill both, but in other instances the two codes may be mutually exclusive (or bundled). So the best way to know that answer is to check the Medicare Correct Coding Initiative tables. Q: If a repair requires both a flap and a graft, can both be billed? A: Yes, both can be billed.
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Coding for Repairs and Excisions
C PT rules aren’t easy. Many codes have nebulous descriptors while others have almost no guidelines at all. Sometimes the way a code should be used in the real world isn’t defined very well in the CPT book at all. One of the most commonly misunderstood sections of the Integumentary System (e.g., CPT codes 10000 to 19999) involves the use of the excision codes (CPT codes 11400 to 11646) and the use of intermediate and complex repairs (CPT codes 12031 to 12057, and 13100 to 13153 respectively). In this article, I’ll answer some questions that I get asked over and over again. Many of the questions have to do with adding. You’ll see what I mean as you read continue reading. Q: I frequently see patients who present with multiple nevi that need to be sent for pathologic review. Often, I’ll see two moles in very close proximity to one another that need to be excised. When I excise lesions that are so close, I can usually remove both lesions with one ellipse. For example, I may have two moles — one 4 mm/d and one 5 mm/d. In a case such as this, I would remove both with one ellipse. My question regarding this practice is three-fold: 1. Can I bill one excision for the 4-mm nevus and one excision for the 5-mm nevus, or must I add them together and bill only one excision? 2. If I can bill both separately, how do I measure their size since I need this information in order to comply with the new method for billing excisions that requires calculating the size of the actual lesions and adding that to the size of the conservative margins? 3. If I can bill both separately, do I need any modifiers? A: I’ll answer these questions in the order they were asked. 1. Bill each one separately. Excisions are never added together regardless of whether you excise them both in one ellipse or if you excise each one separately. 2. How you determine your measurements depends on how you orient your ellipse. Let’s look at this in two ways: a. Let’s assume that both lesions (located on the patient’s back) are side by side so the width of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each side. Let’s also assume that there was 1 mm between the two lesions and that you took 2-mm margins on the left and right side of the ellipse. So you add (from left to right): 2 + 4 + 1 + 5 + 2 = 14 millimeters or 1.4 centimeters. This measurement represents the width of your ellipse. To get an excised diameter for each lesion, I would take the area between the lesions and divide it in half giving you a 0.5-mm measurement. I would then measure the size of the nevus (4 mm) and the outer margins (2 mm). Add these together with the 0.5 mm and you get your first size; a lesion with an excised diameter of 6.5 mm or 0.65 centimeters. You do the same for the 5-mm lesion. Take 0.5 mm, which represents half of the area between the two lesions, add the lesions size of 5 mm and then add the outer margin of 2 mm. This gives you a lesion with an excised diameter of 7.5 mm or 0.75 cm. Assuming that both lesions are benign, you would bill using CPT codes 11401 and 11401. Let’s also assume that the length of your ellipse was 3.5 centimeters. Based on the type of closure you selected (either an intermediate repair or a complex repair), you bill for the repair using only one repair code. Repairs of the same anatomical classification are always added together. So let’s assume that you did an intermediate repair. You use CPT code 12032 based on a 3.5-cm long defect. b. Let’s assume that both lesions of the back are vertical (one above the other) so the length of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each end of the length of the ellipse. You would use the same measurement process as outlined in example A for determining the excised diameter of each lesion. To determine the length of the ellipse (the size used to select the repair code, if appropriate) assume that there was 1 mm between the two lesions and that you took 3-mm margins on each end of ellipse. So you add (from top to bottom): 3 + 4 + 1 + 5 + 3 = 16 millimeters or 1.6 centimeters. This measurement represents the length of your ellipse. If an intermediate repair was performed, you would bill using CPT code 12031. 3.Yes, you need a modifier in both examples “A” and “B” because you have two CPT codes that are identical. You bill: Example “A” 11401 11401 -76 (or -59 depending on carrier preference) 12032 Example “B” 11401 11401 -76 (or -59 depending on carrier preference) 12031 If the excisions had different CPT codes, such as 11401 and 11402, you would not need any modifiers: 11401 11402 12031 (or 12032) Q: I am always confused about how you know which repairs are added together and which are not. For example, I repair two defects resulting from two excisions. They are both on the trunk, but I close one with an intermediate repair and the other with a complex repair. Must I add the two repairs together and only bill one CPT code since they are both on the trunk? Or, can I bill them separately because they are closed with two different types of techniques; one being an intermediate closure while the other is complex? A: First, the answer is “no”. You do not add together the length of repairs if you are closing defects with different types of closures. You only add together lengths that are: 1. in the same anatomical classification (I’ll discuss this more later). 2. repaired with the same type of repair technique (intermediate or complex). Second, you need to understand the classifications as they are defined by CPT. Classifications refer to anatomical body areas such as trunk, extremities, axillae, scalp, neck, hands, feet, external genitalia, face, ears, eyelids, nose, and lips that are lumped together under one CPT code. (Keep in mind that the size is also a determining factor in code selection.) If two repairs are performed by the same technique (intermediate repair, for example) and are located in the same anatomical classification, then you add together the length of the repairs and bill the one CPT code that represents the sum of the two lengths. Read the charts carefully. The classifications are different for the two types of repairs: intermediate versus complex. For example, layer closure of the scalp, axillae, trunk, and extremities is one classification whereas under the complex repair codes, the trunk is one classification, while the scalp, arms and legs are a separate classification. On the next page are two charts that show the CPT codes and their anatomical classifications. Next, let’s review the classification blocks. The rule is simple: You can never bill more than one code from any one block on the same date of service for the same patient. Q: I’m a Mohs surgeon, and I’d like to know what to do in the following scenario. If I use two different types of flaps (e.g., adjacent tissue transfers), do I add together the sum of the two flaps or can I bill each flap separately? A: Flaps are not added together if two different types of flaps are needed to accomplish one repair. Check for the use of modifiers as some of these codes may be bundled. If they are bundled, you attach modifier -59 to the bundled service since the definition of modifier -59 includes “different procedure”. Q: If a repair cannot be closed by a flap alone, but also requires a complex repair, can both be billed? A: That depends on the CPT codes you wish to bill. In some cases you can bill both, but in other instances the two codes may be mutually exclusive (or bundled). So the best way to know that answer is to check the Medicare Correct Coding Initiative tables. Q: If a repair requires both a flap and a graft, can both be billed? A: Yes, both can be billed.
C PT rules aren’t easy. Many codes have nebulous descriptors while others have almost no guidelines at all. Sometimes the way a code should be used in the real world isn’t defined very well in the CPT book at all. One of the most commonly misunderstood sections of the Integumentary System (e.g., CPT codes 10000 to 19999) involves the use of the excision codes (CPT codes 11400 to 11646) and the use of intermediate and complex repairs (CPT codes 12031 to 12057, and 13100 to 13153 respectively). In this article, I’ll answer some questions that I get asked over and over again. Many of the questions have to do with adding. You’ll see what I mean as you read continue reading. Q: I frequently see patients who present with multiple nevi that need to be sent for pathologic review. Often, I’ll see two moles in very close proximity to one another that need to be excised. When I excise lesions that are so close, I can usually remove both lesions with one ellipse. For example, I may have two moles — one 4 mm/d and one 5 mm/d. In a case such as this, I would remove both with one ellipse. My question regarding this practice is three-fold: 1. Can I bill one excision for the 4-mm nevus and one excision for the 5-mm nevus, or must I add them together and bill only one excision? 2. If I can bill both separately, how do I measure their size since I need this information in order to comply with the new method for billing excisions that requires calculating the size of the actual lesions and adding that to the size of the conservative margins? 3. If I can bill both separately, do I need any modifiers? A: I’ll answer these questions in the order they were asked. 1. Bill each one separately. Excisions are never added together regardless of whether you excise them both in one ellipse or if you excise each one separately. 2. How you determine your measurements depends on how you orient your ellipse. Let’s look at this in two ways: a. Let’s assume that both lesions (located on the patient’s back) are side by side so the width of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each side. Let’s also assume that there was 1 mm between the two lesions and that you took 2-mm margins on the left and right side of the ellipse. So you add (from left to right): 2 + 4 + 1 + 5 + 2 = 14 millimeters or 1.4 centimeters. This measurement represents the width of your ellipse. To get an excised diameter for each lesion, I would take the area between the lesions and divide it in half giving you a 0.5-mm measurement. I would then measure the size of the nevus (4 mm) and the outer margins (2 mm). Add these together with the 0.5 mm and you get your first size; a lesion with an excised diameter of 6.5 mm or 0.65 centimeters. You do the same for the 5-mm lesion. Take 0.5 mm, which represents half of the area between the two lesions, add the lesions size of 5 mm and then add the outer margin of 2 mm. This gives you a lesion with an excised diameter of 7.5 mm or 0.75 cm. Assuming that both lesions are benign, you would bill using CPT codes 11401 and 11401. Let’s also assume that the length of your ellipse was 3.5 centimeters. Based on the type of closure you selected (either an intermediate repair or a complex repair), you bill for the repair using only one repair code. Repairs of the same anatomical classification are always added together. So let’s assume that you did an intermediate repair. You use CPT code 12032 based on a 3.5-cm long defect. b. Let’s assume that both lesions of the back are vertical (one above the other) so the length of your ellipse includes both lesions, the area between the two lesions, and the conservative margin on each end of the length of the ellipse. You would use the same measurement process as outlined in example A for determining the excised diameter of each lesion. To determine the length of the ellipse (the size used to select the repair code, if appropriate) assume that there was 1 mm between the two lesions and that you took 3-mm margins on each end of ellipse. So you add (from top to bottom): 3 + 4 + 1 + 5 + 3 = 16 millimeters or 1.6 centimeters. This measurement represents the length of your ellipse. If an intermediate repair was performed, you would bill using CPT code 12031. 3.Yes, you need a modifier in both examples “A” and “B” because you have two CPT codes that are identical. You bill: Example “A” 11401 11401 -76 (or -59 depending on carrier preference) 12032 Example “B” 11401 11401 -76 (or -59 depending on carrier preference) 12031 If the excisions had different CPT codes, such as 11401 and 11402, you would not need any modifiers: 11401 11402 12031 (or 12032) Q: I am always confused about how you know which repairs are added together and which are not. For example, I repair two defects resulting from two excisions. They are both on the trunk, but I close one with an intermediate repair and the other with a complex repair. Must I add the two repairs together and only bill one CPT code since they are both on the trunk? Or, can I bill them separately because they are closed with two different types of techniques; one being an intermediate closure while the other is complex? A: First, the answer is “no”. You do not add together the length of repairs if you are closing defects with different types of closures. You only add together lengths that are: 1. in the same anatomical classification (I’ll discuss this more later). 2. repaired with the same type of repair technique (intermediate or complex). Second, you need to understand the classifications as they are defined by CPT. Classifications refer to anatomical body areas such as trunk, extremities, axillae, scalp, neck, hands, feet, external genitalia, face, ears, eyelids, nose, and lips that are lumped together under one CPT code. (Keep in mind that the size is also a determining factor in code selection.) If two repairs are performed by the same technique (intermediate repair, for example) and are located in the same anatomical classification, then you add together the length of the repairs and bill the one CPT code that represents the sum of the two lengths. Read the charts carefully. The classifications are different for the two types of repairs: intermediate versus complex. For example, layer closure of the scalp, axillae, trunk, and extremities is one classification whereas under the complex repair codes, the trunk is one classification, while the scalp, arms and legs are a separate classification. On the next page are two charts that show the CPT codes and their anatomical classifications. Next, let’s review the classification blocks. The rule is simple: You can never bill more than one code from any one block on the same date of service for the same patient. Q: I’m a Mohs surgeon, and I’d like to know what to do in the following scenario. If I use two different types of flaps (e.g., adjacent tissue transfers), do I add together the sum of the two flaps or can I bill each flap separately? A: Flaps are not added together if two different types of flaps are needed to accomplish one repair. Check for the use of modifiers as some of these codes may be bundled. If they are bundled, you attach modifier -59 to the bundled service since the definition of modifier -59 includes “different procedure”. Q: If a repair cannot be closed by a flap alone, but also requires a complex repair, can both be billed? A: That depends on the CPT codes you wish to bill. In some cases you can bill both, but in other instances the two codes may be mutually exclusive (or bundled). So the best way to know that answer is to check the Medicare Correct Coding Initiative tables. Q: If a repair requires both a flap and a graft, can both be billed? A: Yes, both can be billed.
