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Medical Coding Uncertain Lesion Excisions With Certainty

 

What to do when the pathology doesn’t correlate to the service supplied.

The principles for cutaneous (pores and skin) excision coding are simple: When the pathology for a lesion is benign, code for excision of benign lesion, 11400-11446; and when the pathology for a lesion is malignant, code for excision of malignant lesion, 11600-11646. However in the actual world, coding isn’t at all times that clear lower. Such is commonly the case when coding for excisions of neoplasms of unsure nature.

Unspecified vs. Unsure: There’s a Distinction

In contrast to an “unspecified neoplasm” prognosis, which implies the tissue has not been evaluated by a pathologist; subsequently, it’s unknown to the surgeon if the tissue is malignant or benign, a neoplasm of “unsure nature” has been totally evaluated by a pathologist; nevertheless, the pathologist was unable to categorise the tissue’s cells as both malignant or benign. In different phrases, the morphology of the cells is unsure. Solely a pathologist can assign unsure nature to a pattern.

As a result of there’s a likelihood that the tissue/cells may behave like malignant tissue/cells, the surgeon will deal with lesions of unsure nature as if they’re malignant lesions by eradicating them with bigger margins to verify all of the questionable tissue is eliminated.

A Case for Re-excision

So, what occurs if the pathology report reveals the pattern from the re-excision carried out at a separate encounter doesn’t include any malignant tissue? Per the Could 2012 CPT® Assistant, even when the next pathology comes again with a distinct prognosis, the re-excision needs to be linked to the unique (malignant) prognosis. Let’s have a look at two examples demonstrating how correct process and prognosis coding impacts fee for re-excision on a affected person who had been recognized with melanoma.

Instance 1

The surgeon re-excised a 2.2 cm space on the neck with 2 cm margins, making the diameter of the excision 6.2 cm. The pattern was despatched to pathology and located to be benign. The prognosis code is C43.4 Malignant melanoma of scalp and neck.
Strict studying of the principles would have you ever code the process as an excision of a benign lesion for the reason that pathology decided the pattern to be benign — 11426 Excision, benign lesion together with margins, besides pores and skin tag (until listed elsewhere), scalp, neck, arms, ft, genitalia; excised diameter over 4.0 cm. This code has 8.00 facility relative worth models (RVUs) with 4.09 work RVUs allotted to the surgeon.
For this encounter, nevertheless, the intent of the surgeon was to verify the affected person’s malignant lesion was absolutely excised, as indicated by the big margins and deep excision. Whereas there’s a benign tissue discovering, the surgeon’s documented intent and method was that for a malignant lesion excision, making the correct process code 11626 Excision, malignant lesion together with margins, scalp, neck, arms, ft, genitalia; excised diameter over 4.0 cm. This service has 8.59 RVUs (4.61 work RVUs). Append modifier 58 if the identical surgeon carried out the re-excision in the course of the postoperative interval for the excision, per CPT® 2022 tips.

Instance 2

The surgeon excised a melanoma on the occipital scalp and a mass on the neck. The operative word said that the neck mass was suspected to be a metastasis from the melanoma and, consequently, wider margins had been excised, eradicating the lesion and the capsule in complete. The pathology report indicated that the neck mass was a benign follicular cyst. Due to the wonderful scientific documentation by the surgeon, the excision of the three.5 cm diameter lesion and margins on the neck needs to be coded as an excision of malignant lesion, 11624 Excision, malignant lesion together with margins, scalp, neck, arms, ft, genitalia; excised diameter 3.1 to 4.0 cm. This code has 6.95 RVUs, in comparison with 5.21 RVUs for 11424 Excision, benign lesion together with margins, besides pores and skin tag (until listed elsewhere), scalp, neck, arms, ft, genitalia; excised diameter 3.1 to 4.0 cm.

This coding is substantiated in CPT® Assistant (Could 1996):

When the morphology of a lesion is ambiguous, selecting the proper CPT process code pertains to the way wherein the lesion was approached relatively than the ultimate pathologic prognosis, for the reason that CPT code ought to replicate the data, talent, time, and energy that the doctor invested within the excision of the lesion. Subsequently, an ambiguous however low suspicion lesion is likely to be excised with minimal surrounding grossly regular pores and skin/comfortable tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous however moderate-to-high suspicion lesion can be excised with average to extensive surrounding grossly regular pores and skin/comfortable tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that finest describes the process as carried out needs to be chosen.

Third-Social gathering Payer Processing of Declare

There’s a good likelihood {that a} third-party payer could deny a declare for excision of a malignant lesion with a prognosis indicating that the lesion is benign or a cyst. If that happens, the apply has two choices:
1. Attraction the denial with a replica of the operative word which reveals the surgeon assumed the lesion was malignant and handled the excision as such. Hopefully, your surgeon provides you a properly written operative word, which demonstrates the medical necessity for excising a malignant lesion. Finest apply can be to incorporate the CPT® Assistant steering present above.
2. Submit the corrected declare for the excision of benign lesion with modifier 22 Elevated procedural companies. Embrace in field 19 that the lesion was assumed to be malignant, growing the service by X %.
You can even do that initially, as an alternative of coding the service as a malignant lesion excision. The operative word ought to present the worth of the service representing 15-35 % greater than the excision of a benign lesion, and the additional work concerned as a result of the surgeon assumed the lesion was malignant. That is sometimes faster than interesting.
Get It in Writing
The distinction in RVUs between benign and malignant lesion excisions isn’t large; it’s extra a matter of creating positive the code most precisely represents the work the surgeon carried out and documented. A Findings or Indications paragraph firstly of the operative word usually supplies a variety of high quality info for the coder and anybody else evaluating the coding, such because the payer.
If the documentation doesn’t clearly clarify the indication(s) for the process (i.e., medical necessity), it’s good protocol to question the surgeon to see in the event that they wish to amend the operative word with the findings/indications that may assist clarify and assist their work. We must always try to code what finest represents the work carried out by the surgeon.

For Extra Info: https://www.aapc.com/weblog/85556-coding-uncertain-lesion-excisions-with-certainty/

 

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