by Connie Eckenrodt, RHIT, CHC
A skin lesion is a superficial growth or patch of skin that is dissimilar from the area surrounding it. The vast majority of skin lesions are non-cancerous, or benign. The physician will determine whether or not a particular lesion is cancerous, or malignant, based on observation and the results of a tissue biopsy. Because CPT classifies lesions as either benign or malignant, it is imperative to wait for the pathology report before selecting CPT or ICD-9 codes to describe the excised lesion(s). (Excision of a malignant lesion is reimbursed at a higher rate.)
To properly assign the correct CPT code for the excision, the following must be determined:
-Type of lesion (benign vs. malignant)
-Site of lesion
-Size of lesion
-Number of lesions
Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus the margins required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). Physicians should document the size of the lesion excision prior to removal. This is a matter of both clinical and coding accuracy. The lesion’s size will decrease as soon as the first incision releases some of the tension on the skin, and the sample will likely shrink further when placed in formaldehyde.
A common coding error is adding the measurements of two or more lesions to determine the code used. NEVER ADD LESION MEASUREMENTS TOGETHER. Instead, report each lesion excision as a separate procedure, with its own linked diagnosis. When reporting multiple excisions of lesions at the same general location, append modifier 59, Distinct procedural service, to the second and subsequent codes.
Excision codes include simple closure and local anesthesia. No additional codes are assigned for closure of wound when it is a simple closure. CPT does allow separate coding for intermediate (12031-12057) and complex (13100-13153) repairs, when performed.
It is important for the coder to remember when an adjacent tissue transfer is performed in conjunction with a lesion excision, the lesion excision is bundled into the code for the adjacent tissue transfer procedure and therefore would not be coded separately. Only the adjacent tissue transfer code is reported.
When a malignant lesion has been excised and a re-excision is performed at the same operative session to ensure that the entire lesion has been removed, the CPT code assigned will be based on the second final widest excised diameter required for complete tumor removal. If the pathology report should reveal no malignant process was pre-sent this would still be appropriate.
If the surgeon performs a re-excision to obtain clear margins at a subsequent operative session for a malignant lesion, the same diagnosis used on the initial excision should be used on the subsequent. This is true even if the pathology report on the second excision returns benign, because the original reason for the re-excision was malignancy.
Physician Documentation Tips: For accurate coding, document the following clinical information in the procedure note when performing an excision of a skin lesion:
– The morphology of each lesion
– The dimensions of each lesion plus the margins required for complete excision of each lesion
– The anatomical site of each lesion
– The surgical technique used to remove each lesion
– The surgical technique used to close each lesion