Mind your coding terms, warns Dr. Kircik, to avoid having RAC auditors down code or issue requests for full refunds. ______________________________ One of the most common questions I encounter during my lectures is when to code a biopsy vs. excision vs. shave removal. While this may seem like a complicated question, the answer is simple: purpose. Why are you doing the procedure? If you don’t know what you are dealing with, it is always a biopsy. By definition, a biopsy entails removal of either the entire lesion or a part of it for purposes of diagnosis and determining whether additional treatment is required. Therefore, when you code a biopsy, you don’t have to hold your billing for the diagnosis. And, you can use ICD code 238.2 (neoplasm of unknown origin) or 782.1 (unknown rash), both codes that make clear you are doing a biopsy because you don’t know what you are dealing with. Beyond Biopsy: Options for Lesion Removal However, if you know what the diagnosis is and the purpose of the procedure is to remove the lesion, the technique of removal will dictate the appropriate CPT code. The choices are: 1. Shave removal CPT Codes 11300-11313 (depending on location and size). 2. Excisions for benign lesions CPT codes 11400-11446 (depending on location and size). 3. Excisions for malignant lesions CPT codes 11600-11646 (depending on location and size). Let’s examine these options. Shave Removal Defined The definition of shave removal is removal of epidermal and dermal lesions without full thickness dermal excision by transverse incision or “slicing” of epidermal and/or dermal lesions. The key words here are “without full thickness,” which will distinguish this technique from regular excision. While these codes don’t specify whether the lesion is benign or malignant, most of us would use the shave removal for benign lesions, such as, seborrheic keratosis, nevi, warts, etc. Importance of Terminology To avoid confusing “coding expert auditors,” I am careful about the terms I use. I prefer to use the term “shave removal” rather than “shave excision” to avoid confusion with regular excision. Similarly, I never use the terms “shave biopsy” or “excisional biopsy,” even though sometimes we want to identify which technique we used for biopsy such as punch vs. shave. Instead of “shave biopsy,” I document that “biopsy was performed with punch” or “biopsy was performed with a #15 blade.” It may be hard to believe that terminology is that important, but when Recovery Audit Contractor (RAC) auditors start to review your notes, they will be looking for every reason justifiable either to down code or request full refunds from providers, because their paychecks will depend on that, and it can all boil down to semantics. Benign Lesion Removal Charging Challenges As I already mentioned, most of us use the shave removal technique to remove benign lesions such as nevi or seborrheic keratosis, which brings up another problem with shave removal codes — determining their purpose and whom to charge, as removal of those benign lesions is not medically necessary. Most third-party payers including Medicare don’t reimburse the removal of benign lesions other than for clearly identified exceptions including irritation, inflammation, infection or obstruction of vision or nasal nare. Therefore, most of the shave removal codes should be charged to the patient with the appropriate waivers. Dealing With Unreasonable Patients The next issue is how to deal with the patient who doesn’t want to pay out of pocket and questions your judgment that his/her lesion is benign, asking how you can determine that “by looking at it for less than 10 seconds.” (I am sure you have heard those remarks before.) I first try to reassure the patient that we will still send the specimen to pathology and if it turns out to be malignant, we will certainly reimburse them for their payment. My own experience with this very issue concerned my removal of what I thought was a seborrheic keratosis. When the pathology report came back as lentigo malignant melanoma in situ, I didn’t know what to tell the patient first upon her return — whether I should give her the good news that I would refund her money, or the bad news that she has a melanoma! In the case of an unreasonable patient whom I don’t want to keep in my practice, I go ahead and do a biopsy — and, remember, the definition of biopsy is to remove a portion of the lesion — and charge it to insurance. On the return visit, when the patient presents with the nevus or seborrheic keratosis still on their face, they are told that the pathology report contains proof that the lesion was benign, and that, because their insurance will not pay for removal of a benign lesion, they will have to pay out of pocket for removal of the remainder of the lesion. This is an absolutely reasonable approach to dealing with an unreasonable patient as long as it is documented in detail for attorneys in the future! Excision Code Considerations Now, let’s look at the excision codes. These codes are also grouped according to site and size. Excision codes are also separated for malignant vs. benign lesions. Therefore, you must have a diagnosis before you perform an excision. The size of the excision depends not only on the lesion but also on its margins, as long as it is reasonable. Certainly, you would not use the margins needed for a melanoma for a benign lesion. The most important thing is to document “full thickness removal” down to subcutaneous tissue. All excision codes include simple closures, but they do not include intermediate or complex closures. Therefore, you can charge intermediate and complex closures in addition to excision codes. However, you will get reimbursed 50% of allowable reimbursement for the CPT code with lesser RVU. The exception to that rule is if you excise a benign lesion 0.5cm or less (CPT code 11400) then you cannot bill an intermediate closure code separately. That is not reimbursable, because this is considered a small defect, which should be closed with simple closure. Also, if you close a defect with a flap or a graft, then you cannot charge for the original excision, regardless of whether it was for a benign or malignant lesion. Mohs micrographic surgery is an exception to that rule. Another caveat is that you cannot use any of the excision or shave removal codes for skin tags. If your diagnosis code is (701.9), then you need to use CPT code 11200 for up to 15 lesions and 11201 for each additional 10 lesions. (Remember if they are not irritated, inflame or infected, it is NOT medically necessary to remove them.) Always remember, just because a CPT code exists does not mean it is OK to bill to a third-party payer or that it is a covered or reimbursable item. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has no conflict of interest with any material presented in this month’s column.
BIOPSY EXCISION
Mind your coding terms, warns Dr. Kircik, to avoid having RAC auditors down code or issue requests for full refunds. ______________________________ One of the most common questions I encounter during my lectures is when to code a biopsy vs. excision vs. shave removal. While this may seem like a complicated question, the answer is simple: purpose. Why are you doing the procedure? If you don’t know what you are dealing with, it is always a biopsy. By definition, a biopsy entails removal of either the entire lesion or a part of it for purposes of diagnosis and determining whether additional treatment is required. Therefore, when you code a biopsy, you don’t have to hold your billing for the diagnosis. And, you can use ICD code 238.2 (neoplasm of unknown origin) or 782.1 (unknown rash), both codes that make clear you are doing a biopsy because you don’t know what you are dealing with. Beyond Biopsy: Options for Lesion Removal However, if you know what the diagnosis is and the purpose of the procedure is to remove the lesion, the technique of removal will dictate the appropriate CPT code. The choices are: 1. Shave removal CPT Codes 11300-11313 (depending on location and size). 2. Excisions for benign lesions CPT codes 11400-11446 (depending on location and size). 3. Excisions for malignant lesions CPT codes 11600-11646 (depending on location and size). Let’s examine these options. Shave Removal Defined The definition of shave removal is removal of epidermal and dermal lesions without full thickness dermal excision by transverse incision or “slicing” of epidermal and/or dermal lesions. The key words here are “without full thickness,” which will distinguish this technique from regular excision. While these codes don’t specify whether the lesion is benign or malignant, most of us would use the shave removal for benign lesions, such as, seborrheic keratosis, nevi, warts, etc. Importance of Terminology To avoid confusing “coding expert auditors,” I am careful about the terms I use. I prefer to use the term “shave removal” rather than “shave excision” to avoid confusion with regular excision. Similarly, I never use the terms “shave biopsy” or “excisional biopsy,” even though sometimes we want to identify which technique we used for biopsy such as punch vs. shave. Instead of “shave biopsy,” I document that “biopsy was performed with punch” or “biopsy was performed with a #15 blade.” It may be hard to believe that terminology is that important, but when Recovery Audit Contractor (RAC) auditors start to review your notes, they will be looking for every reason justifiable either to down code or request full refunds from providers, because their paychecks will depend on that, and it can all boil down to semantics. Benign Lesion Removal Charging Challenges As I already mentioned, most of us use the shave removal technique to remove benign lesions such as nevi or seborrheic keratosis, which brings up another problem with shave removal codes — determining their purpose and whom to charge, as removal of those benign lesions is not medically necessary. Most third-party payers including Medicare don’t reimburse the removal of benign lesions other than for clearly identified exceptions including irritation, inflammation, infection or obstruction of vision or nasal nare. Therefore, most of the shave removal codes should be charged to the patient with the appropriate waivers. Dealing With Unreasonable Patients The next issue is how to deal with the patient who doesn’t want to pay out of pocket and questions your judgment that his/her lesion is benign, asking how you can determine that “by looking at it for less than 10 seconds.” (I am sure you have heard those remarks before.) I first try to reassure the patient that we will still send the specimen to pathology and if it turns out to be malignant, we will certainly reimburse them for their payment. My own experience with this very issue concerned my removal of what I thought was a seborrheic keratosis. When the pathology report came back as lentigo malignant melanoma in situ, I didn’t know what to tell the patient first upon her return — whether I should give her the good news that I would refund her money, or the bad news that she has a melanoma! In the case of an unreasonable patient whom I don’t want to keep in my practice, I go ahead and do a biopsy — and, remember, the definition of biopsy is to remove a portion of the lesion — and charge it to insurance. On the return visit, when the patient presents with the nevus or seborrheic keratosis still on their face, they are told that the pathology report contains proof that the lesion was benign, and that, because their insurance will not pay for removal of a benign lesion, they will have to pay out of pocket for removal of the remainder of the lesion. This is an absolutely reasonable approach to dealing with an unreasonable patient as long as it is documented in detail for attorneys in the future! Excision Code Considerations Now, let’s look at the excision codes. These codes are also grouped according to site and size. Excision codes are also separated for malignant vs. benign lesions. Therefore, you must have a diagnosis before you perform an excision. The size of the excision depends not only on the lesion but also on its margins, as long as it is reasonable. Certainly, you would not use the margins needed for a melanoma for a benign lesion. The most important thing is to document “full thickness removal” down to subcutaneous tissue. All excision codes include simple closures, but they do not include intermediate or complex closures. Therefore, you can charge intermediate and complex closures in addition to excision codes. However, you will get reimbursed 50% of allowable reimbursement for the CPT code with lesser RVU. The exception to that rule is if you excise a benign lesion 0.5cm or less (CPT code 11400) then you cannot bill an intermediate closure code separately. That is not reimbursable, because this is considered a small defect, which should be closed with simple closure. Also, if you close a defect with a flap or a graft, then you cannot charge for the original excision, regardless of whether it was for a benign or malignant lesion. Mohs micrographic surgery is an exception to that rule. Another caveat is that you cannot use any of the excision or shave removal codes for skin tags. If your diagnosis code is (701.9), then you need to use CPT code 11200 for up to 15 lesions and 11201 for each additional 10 lesions. (Remember if they are not irritated, inflame or infected, it is NOT medically necessary to remove them.) Always remember, just because a CPT code exists does not mean it is OK to bill to a third-party payer or that it is a covered or reimbursable item. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has no conflict of interest with any material presented in this month’s column.
Mind your coding terms, warns Dr. Kircik, to avoid having RAC auditors down code or issue requests for full refunds. ______________________________ One of the most common questions I encounter during my lectures is when to code a biopsy vs. excision vs. shave removal. While this may seem like a complicated question, the answer is simple: purpose. Why are you doing the procedure? If you don’t know what you are dealing with, it is always a biopsy. By definition, a biopsy entails removal of either the entire lesion or a part of it for purposes of diagnosis and determining whether additional treatment is required. Therefore, when you code a biopsy, you don’t have to hold your billing for the diagnosis. And, you can use ICD code 238.2 (neoplasm of unknown origin) or 782.1 (unknown rash), both codes that make clear you are doing a biopsy because you don’t know what you are dealing with. Beyond Biopsy: Options for Lesion Removal However, if you know what the diagnosis is and the purpose of the procedure is to remove the lesion, the technique of removal will dictate the appropriate CPT code. The choices are: 1. Shave removal CPT Codes 11300-11313 (depending on location and size). 2. Excisions for benign lesions CPT codes 11400-11446 (depending on location and size). 3. Excisions for malignant lesions CPT codes 11600-11646 (depending on location and size). Let’s examine these options. Shave Removal Defined The definition of shave removal is removal of epidermal and dermal lesions without full thickness dermal excision by transverse incision or “slicing” of epidermal and/or dermal lesions. The key words here are “without full thickness,” which will distinguish this technique from regular excision. While these codes don’t specify whether the lesion is benign or malignant, most of us would use the shave removal for benign lesions, such as, seborrheic keratosis, nevi, warts, etc. Importance of Terminology To avoid confusing “coding expert auditors,” I am careful about the terms I use. I prefer to use the term “shave removal” rather than “shave excision” to avoid confusion with regular excision. Similarly, I never use the terms “shave biopsy” or “excisional biopsy,” even though sometimes we want to identify which technique we used for biopsy such as punch vs. shave. Instead of “shave biopsy,” I document that “biopsy was performed with punch” or “biopsy was performed with a #15 blade.” It may be hard to believe that terminology is that important, but when Recovery Audit Contractor (RAC) auditors start to review your notes, they will be looking for every reason justifiable either to down code or request full refunds from providers, because their paychecks will depend on that, and it can all boil down to semantics. Benign Lesion Removal Charging Challenges As I already mentioned, most of us use the shave removal technique to remove benign lesions such as nevi or seborrheic keratosis, which brings up another problem with shave removal codes — determining their purpose and whom to charge, as removal of those benign lesions is not medically necessary. Most third-party payers including Medicare don’t reimburse the removal of benign lesions other than for clearly identified exceptions including irritation, inflammation, infection or obstruction of vision or nasal nare. Therefore, most of the shave removal codes should be charged to the patient with the appropriate waivers. Dealing With Unreasonable Patients The next issue is how to deal with the patient who doesn’t want to pay out of pocket and questions your judgment that his/her lesion is benign, asking how you can determine that “by looking at it for less than 10 seconds.” (I am sure you have heard those remarks before.) I first try to reassure the patient that we will still send the specimen to pathology and if it turns out to be malignant, we will certainly reimburse them for their payment. My own experience with this very issue concerned my removal of what I thought was a seborrheic keratosis. When the pathology report came back as lentigo malignant melanoma in situ, I didn’t know what to tell the patient first upon her return — whether I should give her the good news that I would refund her money, or the bad news that she has a melanoma! In the case of an unreasonable patient whom I don’t want to keep in my practice, I go ahead and do a biopsy — and, remember, the definition of biopsy is to remove a portion of the lesion — and charge it to insurance. On the return visit, when the patient presents with the nevus or seborrheic keratosis still on their face, they are told that the pathology report contains proof that the lesion was benign, and that, because their insurance will not pay for removal of a benign lesion, they will have to pay out of pocket for removal of the remainder of the lesion. This is an absolutely reasonable approach to dealing with an unreasonable patient as long as it is documented in detail for attorneys in the future! Excision Code Considerations Now, let’s look at the excision codes. These codes are also grouped according to site and size. Excision codes are also separated for malignant vs. benign lesions. Therefore, you must have a diagnosis before you perform an excision. The size of the excision depends not only on the lesion but also on its margins, as long as it is reasonable. Certainly, you would not use the margins needed for a melanoma for a benign lesion. The most important thing is to document “full thickness removal” down to subcutaneous tissue. All excision codes include simple closures, but they do not include intermediate or complex closures. Therefore, you can charge intermediate and complex closures in addition to excision codes. However, you will get reimbursed 50% of allowable reimbursement for the CPT code with lesser RVU. The exception to that rule is if you excise a benign lesion 0.5cm or less (CPT code 11400) then you cannot bill an intermediate closure code separately. That is not reimbursable, because this is considered a small defect, which should be closed with simple closure. Also, if you close a defect with a flap or a graft, then you cannot charge for the original excision, regardless of whether it was for a benign or malignant lesion. Mohs micrographic surgery is an exception to that rule. Another caveat is that you cannot use any of the excision or shave removal codes for skin tags. If your diagnosis code is (701.9), then you need to use CPT code 11200 for up to 15 lesions and 11201 for each additional 10 lesions. (Remember if they are not irritated, inflame or infected, it is NOT medically necessary to remove them.) Always remember, just because a CPT code exists does not mean it is OK to bill to a third-party payer or that it is a covered or reimbursable item. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has no conflict of interest with any material presented in this month’s column.
