\Part 2 of 2 in a series
Biopsies
One of the most common codes you will use in dermatology is for skin biopsy. In most cases, you should use 11100 for the first biopsy (shave or punch) and 11101 for each additional biopsy. For example, if you perform five biopsies you would bill 11100 and 11101 with a quantity of four for a total of five. When shouldn’t you use these codes?
– Use shave removal codes if your intention is to remove the entire lesion and not just sample it. For example, if a patient has a big irritated, bleeding seborrheic keratosis and you shave it off, your intention is to remove the entire lesion for symptomatic relief. Even if you send it for pathology to confirm your clinical diagnosis, you should still bill this as a shave removal and not a biopsy.
– If you remove an entire lesion using a punch biopsy tool, you can code for this as an excision and not a biopsy. For example, if you use a 6mm punch to remove a 5mm epidermoid cyst, you should code this as a benign excision, not a biopsy./p>
– Some sites on the body have their own biopsy codes which may reimburse more than 11100, so it is worth looking these up. Sites include the external ear, eyelid, lip, nail unit, penis, vulva or perineum, and tongue.
Injections
For most injections you can use the code 11900 for up to and including seven lesions, or 11901 if you inject more than seven lesions. You should also bill for the medication injected using the J code assigned to that medication. Injection of toxins for hyperhidrosis has separate codes such as 64650 for chemodenervation of both axillae.
Destruction
When billing for destruction, you need to first determine if you are in the category of benign, pre-malignant (actinic keratosis) or malignant. If benign, you should bill 17110 if it is up to or fewer than 14 lesions, or 17111 if you treat more than 14 lesions. This code doesn’t cover skin tags – they have their own code 11200 for up to 15 lesions and 11201 for 15 or more.
For actinic keratoses, you need to keep track of how many lesions you treat and bill that specific quantity. The first lesion is always 17000. For lesions 2-14 you bill 17000 and 17003 with the quantity over one that you treated. If you treat 15 or more actinic keratoses, you only bill 17004. For example, if you treat six lesions, you would bill 17000 and 17003 with a quantity of five for a total of six lesions. If you treat 20 lesions, you would only bill 17004 (since it is more than 14).
For destruction of malignant lesions, the billing is based on the size and location of the area treated. If you are performing an electrodessication and curettage, you should measure after you curette but before you electrodessicate.
Just as with biopsies, there are special codes for some sites of destruction. These include the anus, penis and vulva. Some companies that manufacture cryotherapy devices have convenient tables of destruction codes on their websites that you can use as a quick reference. These anogenital codes are separated into simple vs extensive and these terms are not clearly defined. You should use your judgement and justify in your documentation when you use the extensive code. There are also different codes for these areas based on the type of destruction: chemical, cryotherapy, electrodessication or laser.
Excision
Excisions are coded based on location, size of the lesion, and malignant or benign. Remember that the size should be the total diameter at the widest part including the margin. For example, a 5mm x 8mm basal cell carcinoma excised with a 4mm margin would be billed as 1.6cm malignant excision (8mm + 4mm + 4mm). Some dermatologists will wait to submit the billing until the pathology is available so they can bill as malignant if the pathology report shows that.
If you excise more than one lesion in the same size range and same location you must bill for it twice and use a 59 modifier to note that they were separate procedures.You can use soft tissue excision codes for deeper lesions such as deep cysts and lipomas. Keep in mind that these codes include an intermediate repair so you should only bill a separate repair if it is complex.
Repairs
Skin excision codes include a simple repair. You should only bill for a repair if you do something more than a simple repair: intermediate or complex. A simple repair is a single layer of sutures. An intermediate repair is a layered closure. A complex repair is “more than a layered closure (viz. scar revision, debridement, avulsion), extensive undermining, stents or retention sutures.” The term “extensive undermining” is not defined so you should use your best judgement. If you are doing more than you would in your average closure then consider billing it as complex. You should state in your documentation why you needed to use a complex repair. And what made it complex to support your billing.
If more than one repair falls in the same size range and same area, instead of billing that code twice, simply add the lengths together and bill once based on this summed length. For example, if you excise two nevi on the back and perform an intermediate repair on each measuring 2.6cm and 5.5cm, you would add them together for a total length of 8.1 cm and bill 12034 (Intermediate repair trunk 7.6-12.5cm).
Summary
As you can see, medical billing is not straightforward and is something that you need to study and learn. Consider looking for courses in billing at conferences and read the billing question & answer sections that appear in several journals.
