Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details, providers run the risk of downcoding or filing inaccurate claims based on poor documentation.
This article will focus on the ins and outs of lesion removals, and some of the common coding pitfalls that are frequently associated with these procedures.
An excision is the surgical removal or resection of a diseased part by an incision through the dermal layer of the skin, and may be performed on either benign or malignant skin lesions. The different types of benign skin lesions include: moles, epidermoid or sebaceous cysts, non-cancerous neoplasms, integumentary lipomas, nevi, warts, seborrheic keratoses, and more. Malignant lesions include basal and squamous cell carcinoma, melanomas, and metastatic skin lesions.
Excisions for benign lesions (11400-11446) and malignant lesions (11600-11646) are minor surgical procedures with a 10-day global period. Local anesthesia, a biopsy of the lesion, and an evaluation and management (E/M) examination are all included in the global surgical package.
Note: Wound repairs must normally be performed to correct the defect caused by the surgical excision of a lesion.
All simple wound repairs are included in the surgical package of the excision, and may not be reported separately. A simple wound repair requires only a one layer of the epidermal/dermal skin layers, or subcutaneous tissues.
The following steps will help you to select the appropriate code for an excised lesion:
Step 1 – Determine the type of lesion from the pathology report
§ Benign (See 11400-11471.)
§ Malignant (See 11601-11646.)
Step 2 – Identify the anatomic site
§ Trunk, arms, or legs
§ Scalp, neck, hands, feet, or genitalia
§ Face, ears, eyelids, nose, lips, or mucous membranes (benign excisions only)
§ Sweat glands (benign excisions only)
Step 3 – Calculate the size of the excision (lesion size + margins)
§ Excision size is determined prior to the excision
§ Excision size is not measured by the size of the surgical wound left behind, or the size of the excised sample sent to the lab
§ Excision size is measured in centimeters
Step 4 – Assign a procedure code based on data from steps 1 thru 3
Step 5 – Assign an additional code for intermediate or complex repairs
§ Intermediate Repairs (See 12001-12021.)
§ Complex Repairs (See 13100-13160.)
Note: If the wound repair or closure requires an Adjacent Tissue Transfer or Rearrangement (such as a Z-plasty or a rotation flap), the excision is not reported separately, but is included in the surgical package for the Adjacent Tissue Transfer or Rearrangement (See 14000-14350.).
Coding Wound Repairs.
All excisions include a simple closure as part of the surgical package, and therefore, may not be billed separately. However, for excisions that require more than a simple closure, coders can report either an intermediate (12031-12057) or complex (13100- 13160) repair, in addition to the excision. Wound repair codes should only be used when the physician uses sutures, staples, or tissue adhesives to close a wound. If a physician only uses adhesive strips to close a wound, the repair must be reported using an E/M code (99201-99499) instead.
The following steps will help you to code for a wound repair:
Step 1 – How was the wound closed?
§ Adhesive strips only (See 99201-99499.)
§ Sutures or staples, with or without tissue adhesives (See 12001-13160.)
Step 2 – What type of closure did the physician perform?
§ Simple - A single layered closure of the skin (epidermal or dermal) or subcutaneous tissues (Report no additional wound repair code if it is performed as part of an excision.)
§ Intermediate - A layered closure of one or more of the deeper layers of subcutaneous tissue and (non-muscle) fascia, plus a single layered closure of the skin (epidermal or dermal) (See 12031-12057.)
§ Complex - A repair that requires more than a layered closure to close the wound. The additional work may include a scar revision, debridment (for complicated lacerations or avulsions), extensive undermining, stents, and/ or retention sutures (See 13100-13160.)
Step 3 – On what anatomic site was the wound repair performed?
§ Scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet) (See 12001-12007.)
§ Face, ears, eyelids, nose, lips, and/or mucous membranes (See 12011-12018.)
§ Scalp, axillae, trunk, and/or extremities (excluding hands and feet) (See 12031-12037)
§ Neck, hands, feet, and/or external genitalia (See 12041-12047.)
§ Face, ears, eyelids, nose, lips, and/or mucous membranes (See 12051-12057.)
§ Trunk (See 13100-13102.)
§ Scalp, arms, and/or legs (See 13120-13122.)
§ Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet (See 13131-13133.)
§ Eyelids, nose, ears, and/or lips (See 13150-13153.)
Step 4 – Assign a repair code based on the total lengths of all wound repairs that are performed in the same anatomic group under the same classification (intermediate or complex).
A 2.5 cm intermediate repair on the right shoulder, a 1.0 cm intermediate repair on the scalp, and a 1.0 cm intermediate repair on the left shoulder would be coded as12032, Wound Repair, Intermediate, 2.6 cm to 7.5 cm.
Adjacent Tissue Transfer or Rearrangement
For complex excisions that are very large or in areas with little to no margins available, an intermediate or complex wound repair may not be possible. Other wound repairs commonly performed with excisions are Adjacent Tissue Transfers or Rearrangements (14000-14350). An Adjacent Tissue Transfer or Rearrangement (sometimes referred to as a reconstructive repair) may include one of the following:
§ V-Y plasty
§ Rotation flap
§ Random island flap
§ Advancement flap
Adjacent Tissue Transfers or Rearrangements involve the creation of two defects. The primary defect is created when the lesion or skin anomaly is excised. The secondary defect is produced by the surgical creation of a tissue flap that is used to close the primary defect. Tissue flaps are created by surgically freeing healthy skin and underlying subcutaneous tissue and/or fascia adjacent to or near the wound site, leaving the base of the tissue flap connected to one or more borders of the donor site. The tissue flap is then used to cover the wound created by the excision.
Note: If a skin graft or additional flap is necessary to close the secondary defect, report an additional code from 15100-15431.
Code selection is based on two factors: anatomic site and the area of the total body surface created by the primary and secondary defects. To assign the appropriate procedure code, follow the steps below:
Step 1 – Determine the anatomic site of the procedure
§ Trunk (14000-14001)
§ Scalp, Arms, and/or legs (14020-14021)
§ Forehead, cheeks, chin, mouth, neck, axillae, genitalia, and/or hands (14040-14041)
§ Eyelids, nose, ears, and/or lips (14060-14061)
§ Finger and/or Toe (14350)
Note: For code 14350, Filleted finger or toe flap, it is not necessary to calculate the area of the defects in order to assign the code.
Step 2 – Calculate the total area of the defects to select the appropriate code [Total Body Surface (Area of 1º Defect + Area of 2º Defect)]
§ 10 sq cm or less (codes are specific to anatomic site)
§ 10.1 sq cm to 30.0 sq cm (codes are specific to anatomic site)
§ 30.1 sq cm to 60.0 sq cm, any location (14301)
§ Each additional 30.0 sq cm, any location (14302)
Primary Defect: 2.0 cm x 2.0 cm = 4.0 sq cm
Secondary Defect: 2.0 cm x 4.0 cm = 8.0 sq cm
Total Area (Primary + Secondary): 4.0 sq cm + 8.0 sq cm = 12.0 sq cm
Modifiers with Multiple Procedures
With some excisions, it may be necessary to report more than one procedure code in order to capture the full services performed. When multiple surgical procedures are performed on the same patient, by the same physician, on the same day, during the same encounter, add modifier 51 (Multiple Procedures) to all subsequent procedures.
A patient has a 2.0 cm benign lesion removed from her neck. The physician also performs a 2.5 cm intermediate wound repair on the excised site. The physician’s services are reported as 11420 and 12001-51.
Note: Remember not to add modifier 51 to any procedures that are classified as add-on procedures or modifier 51 exempt.
If multiple procedures are performed on the same day, but the excisions or wound repairs involve different anatomic sites, it may be necessary to add modifier 59 (Distinct Procedural Service) to the subsequent procedures. Modifiers with Multiple Procedures (Continued) If the patient is already in a post-operative (post-op) period when the excisions or wound repairs are performed, one of the following modifiers may be required for accurate coding:
§ Modifier 58 (Staged or Planned Procedure)
§ Modifier 78 (Unplanned return to the operating room following the initial procedure for a related procedure)
§ Modifier 79 (Unrelated procedure by the same physician)
For separate, unrelated, E/M service performed on the same day as a surgical procedure, do not forget to add one of the following modifiers to the E/M code:
§ Modifier 24 – Unrelated E/M service by the same physician during a post-op period
§ Modifier 25 – Significant, separate E/M by the same physician on the same day as another procedure or service
§ Modifier 57 – Decision for surgery