Q: Is there a method to determine the best CPT code for lesion removals?
A: Yes. From an anatomical perspective, lesions can exist on various ocular structures. For example, they may be corneal, conjunctival, lacrimal or located on the eyelid. Once you determine the location, the next step is to determine the histology, whether the lesion is benign, malignant or uncertain, and method of removal—cut, scrape, excise, cauterize, incise or drain. Was closure necessary and, if so, was it simple or complex? Once you have answered these questions, you will have narrowed the choice of CPT codes to match your documentation.
Q: Do lesion removal codes have a global period, and may we file for an office visit on the day of the removal?
A: Lesion removals are minor procedures and have either zero or 10 postop days. Because these are minor procedures, the office visit is usually bundled with the lesion removal unless your documentation includes a separately identifiable service supporting the use of modifier -25 for the office visit.
Q: What is the best way to document the procedure?
A: Best practices would be to have a separate operative report for the procedure. It should contain the indications for the procedure, a description of the procedure and discharge instructions. A clearly documented consent, either written or verbal, for the procedure should also be in the medical record.
Q: What is the difference between the three CPT codes that describe a chalazion removal?
A: The various codes differentiate between the number of removals, location of chalazia and whether general anesthesia or hospitalization is required. For a single chalazion, code as CPT 67800; if more than one is removed on the same eyelid, use CPT 67801; if there are multiple located on different eyelids, use 67805. CPT 67808 is reserved for an excision under general anesthesia and/or requiring hospitalization, and is used whether a single or multiple chalazia are removed under these conditions. This is more commonly used for pediatric patients.
Q: Is it appropriate to use CPT 67840, excision of lesion of eyelid (except chalazion) without closure or with simple direct closure, for all eyelid lesions?
A: No. The CPT manual contains instructions at the beginning of the section for Excisions / Destructions just above CPT 67800. It states: “Codes for removal of lesions include more than skin (ie., involving lid margin, tarsus, and/or palpebral conjunctiva.” The procedure note describing the surgery should describe removal of more than just skin to support the use of this code.
Q: If 67840 is not appropriate and the lesion removal is only skin, what codes should be considered?
A: The 11xxx series of codes relates to the integumentary system. More specifically, 1144x addresses benign lesions of face, ears, eyelids, nose and lips. CPT 1164x codes are used for malignant lesions of those same areas. The range of codes from 11440 to 11446 and 11640 to 11646 are distinguished based on the size of the removal. The CPT descriptors contain measurements using centimeters. For example, CPT 11441 describes a lesion that is 0.6 to 1.0 cm.
Q: How is the size of the excision calculated?
A: When measuring the removal to select the appropriate CPT code, measure the lesion itself at its greatest clinical diameter and the margin required to accomplish a complete excision. Document the size in the procedure note.
Q: If the surgeon is unsure of the histology of the skin lesion and submits the specimen to pathology, can this be coded and filed on the date of service?
A: We don’t recommend it. Without the pathology report, you are unable to accurately select a CPT code for the removal. These claims should be set aside until the pathology report has been returned and a code can be selected from the 1144x series or the 1164x series.
Q: What is the difference between an excisional biopsy and a biopsy?
A: Typically a biopsy indicates that a portion of the lesion is removed and sent to pathology for evaluation. These are coded as 67810 if it is more than just skin. However, if the entire lesion is removed and sent for pathology, and it is more than just skin, you have met the criteria for lesion removal, 67840.
Q: Does Medicare reimburse removal of benign lesions?
A: Maybe. Few Medicare contractors publish local policies on lesion removals to provide coverage guidance. WPS, Medicare contractor for several Midwest states, publishes a local coverage determination that states:
“Medical Indications – There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:
The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or
1. The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or
2. The lesion obstructs an orifice; or
3. The lesion clinically restricts vision; or
4. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or
5. A prior biopsy suggests or is indicative of lesion malignancy; or
6. The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma.”
It further states: “A medical record statement of ‘irritated skin lesion’ is insufficient justification for lesion removal when solely used to reference a patient’s complaint or a physician’s physical findings.”
Q: Is closure of the wound or an adjacent tissue transfer separately billable?
A: Simple closure is included with the excision codes. Intermediate or complex closure might be separately billed. CPT instructs to use only the adjacent tissue transfer code (14000 to 14302) if performed in conjunction with the lesion removal. The removal is included.
Q: Do third-party payers reimburse for the removal of skin tags?
A: Rarely. Skin tag removal, CPT 11200, is usually considered cosmetic and the patient is financially responsible. For regular Medicare, practices should secure an Advance Beneficiary Notice of Noncoverage (ABN) informing the patient of non-coverage and patient liability. If coverage is uncertain, the claim can be filed with modifier -GA; if cosmetic, the claim may be filed with modifier -GY. A financial waiver is also required for Medicare Advantage plans and commercial insurance, but check with the payer for its process and requirements.
Q: Are there additional ophthalmic surgical codes to consider?
A: Yes. Depending on the complexity of the removal and repair, codes in the 67930 to 67975 section may apply.
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.