Coding and documentation clarity

By Alexander Miller, MD, April 2, 2018

You biopsy a suspected drug eruption and document the following: “Punch biopsy done. Return in 1 weeks for suture removal.” Is that sufficient documentation?

I see a dichotomy of documentation relating to surgical procedures. Many electronic health record (EHR) programs spew out a long string of detailed verbiage regarding a simple biopsy procedure, as if payment were predicated upon a word count. Others are short and minimalist. What is best? Well, when documenting a procedure I think of what I would want to see if I were perusing records that a patient had brought to me. A chart auditing insurer may also want evidence of medical necessity recorded in addition to a description of the procedure.

The documentation essentials are the following:

1. Why was the procedure done?
   The indications can be implied (as in a biopsy, to determine a tumor type or to narrow down a differential diagnosis). If you think that it would not be clear to a health professional or insurer, then document it.

2. What exactly was done?
   In the case above, the size of the punch and the anatomic location of the biopsy are good to specify. If more than one biopsy was done on a single or multiple lesions, then these details are best recorded. If the biopsy defect was closed, then how and with what suture should be listed. If it was a saucerize biopsy, say of a pigmented lesion, then it is helpful to specify whether the intent was to fully remove the lesion for histopathologic examination, or whether only a portion of a lesion was removed. If hemostasis was needed, then how was that achieved?

3. Record the type of anesthetic used and, if an excision, the volume used.

4. Lastly, list how the biopsy results will be transmitted to the patient.

5. Once all has been recorded, then the note should be authenticated with a signature, either written or electronic.

The AAD has released a new manual, Principles of Documentation for Dermatology, which provides extensive guidance for optimal documentation. It is a good resource to have.

A common coding snafu leading to non-reimbursement for a medically necessary and legitimately done procedure relates to global surgical packages. The global surgical package includes pre-operative, intraoperative, and immediate post-operative services as well as zero-, 10-, or 90-day follow-up periods.

The 10- and 90-day global periods include a variety of post-operative care, such as wound checks and bandage changes, when these are done during the global period and, if dealing with Medicare, any complications that may arise which do not require additional trips to the operating room.

Unrelated services provided during a global period (new E/M evaluation, new surgically treated lesion) must be identified with an appropriate modifier appended to the primary service code, indicating that the new service is distinct from the original surgical procedure.

Typical modifiers used during global periods are:

24: Unrelated E/M Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

25: Significant, Separately Identifiable E/M Service by the Same Physician Or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

57: Decision for Surgery (refers to E/M service resulting in a decision to perform a 90-day global surgery the day of or day after the evaluation)

58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

78: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Post-operative Period (does not limit its use to the treatment of complications)

79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Global periods most relevant to dermatology stratify as follows:

A global surgery fact sheet is available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Additional material is printed in the “Medicare Claims Processing Manual,” Chapter 12, Section 40, found at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf.

Example1: You destroy 15 actinic keratoses on May 1. On May 11 the patient returns with an exophytic, tender dorsal hand lesion that you suspect is a squamous cell carcinoma. You biopsy the lesion and code CPT code 11100 for the biopsy.

Answer: Incorrect. The biopsy procedure falls on day 10 following the destruction of actinic keratoses. Destructions are subject to a 10-day global period. Consequently, a 79 modifier should be appended to 11100 to indicate that a procedure unrelated to the destruction was done. Global periods for minor surgical procedures include the day of the procedure and 10 days starting the day after the procedure. In the above example the global period’s last day is May 11.

Example 2: One week after a two-stage Mohs surgical excision of an ear basal cell carcinoma you do a delayed full thickness skin graft. As the reconstruction is done only seven days after the initial surgery, you specify the grafting with CPT^® code 15260-79.

Answer: Incorrect. No modifier is required, as Mohs surgery is a zero-day global procedure.

Example 3: A patient has a lentigo maligna on the cheek excised with a “slow Mohs” procedure, whereby an excision with margins is done, and the outer rim margins are sectioned tangentially and assessed microscopically by a pathologist. Two rounds of excisions, done within one week of each other, are required for clearing the tumor. The first excision results in a 2.8 cm maximum excision diameter and the second consists of an extra 4 mm wide excised strip of skin, producing a final maximum excision diameter of 3.2 cm following the final surgical encounter. The defect is then repaired. The first excision is billed as CPT 11643 (malignant excision, excised diameter 2.1 to 3.0 cm), and the second, as 11640 (excised diameter 0.5 cm or less).

Answer: Incorrect. Surgical procedures are to be billed with the date that they are performed. Consequently, the first excision should be billed as presented, and the second one as 11640-58, indicating that a staged or related procedure was done during the postoperative period. The above example is missing the 58 modifier. If the specimen were processed with the “spaghetti” or “squared” techniques, frozen section slides read out by a pathologist on the same day, and both excisions done on the same day, then only the final diameter of the excision, 3.2 cm, would be used to determine one, unified billing, that being CPT® code 11644 (excised diameter 3.1 to 4.0 cm) in this case.

Example 4: Nine days following a diagnostic excision of a pigmented lesion the patient comes in for suture removal and discussion of pathology results. You remove the sutures and discuss pathology results. Since the pigmented lesion was atypical, you do a complete skin examination looking for any other atypical nevomelanocytic lesions and generate and discuss a treatment plan. You bill an appropriate level of evaluation and management (99212, 99213) for the encounter.

Answer: Correct. Although excisions have a 10-day global period, further examination and treatments based upon histopathology interpretations are not included in the global surgical package. Appropriate separate billing is justified and billable with modifier 24 appended, indicating that an E/M unrelated to the services included in the global period was done.

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