Biopsy coding in 2019: Part 3

By Alexander Miller, MD, January 1, 2019

Now that you are certain that the new skin biopsy codes are specified by technique for 2019, you may be wondering how combinations of biopsy techniques done on the same day should be reported. It is obvious that multiples of tangential biopsies, CPT 11102, are used with add-on code 11103, multiples of punch biopsy, 11104, are coded with 11105, and additional incisional biopsies, 11106, are reported with pertinent multiples of 11107.

What happens when more than one biopsy technique is done on a patient during a single service encounter? The CPT^® indicates that only one primary code should be used regardless of whether two or three different biopsy techniques are used. Which code is primary to which? It’s actually conceptually simple: The bigger primary CPT^® code number trumps the smaller ones.

Incisional biopsy (11106) > Punch biopsy (11104) > Tangential biopsy (11102)

Such a hierarchy indicates that when any combination of incisional, punch, and tangential biopsies is done, the incisional biopsy (11106) is the primary code and all others are reported with the add-on codes: 11105 for punch, 11103 for tangential.

When a punch and tangential biopsy are done together, then the punch is coded with 11104 and the tangential with 11103.

Here are some examples:

Single technique

• Three tangential biopsies: 11102, 11103 x2

• Two incisional biopsies: 11106, 11107

Two or more techniques

• One incisional, two tangential: 11106, 11103 x2

• One incisional, one punch, one tangential: 11106, 11105, 11103

• Two punch, two tangential: 11104, 11105, 11103 x2

The biopsy coding hierarchy is fortunately conceptually rather obvious. How about National Correct Coding Initiative (NCCI) Column 1/Column 2 (Procedure to Procedure or PTP) edits for other commonly used dermatologic procedural codes paired with the biopsy codes?

NCCI PTP (Column 1/Column 2) edits indicate two crucial coding determinants:

1. When appropriate, one of two paired primary codes (two different procedures done during the same encounter) may be reported with the 59 modifier.

2. Which of the two paired codes should receive the 59 modifier?

UPDATE:

The 2019 NCCI first quarter edits brought a multitude of changes when appending modifier 59. The NCCI PTP code pairings do not retain their previous, somewhat conceptually challenging, pairing characteristics. In many cases, the new biopsy codes cannot be substituted for the old 11100 biopsy code in the Column 1/Column 2 pairs.

The premalignant destruction (17000, 17004), malignant destruction (17260-17286), benign (11400-1446) and malignant (11660-11646) excision codes are no longer consistently primary to the biopsy codes. This means that whenever any biopsy technique is done along with these procedures, consult the NCCI PTP edits to determine which code receives the modifier. Remember that add-on codes, including add-on biopsy codes, do not require a 59 modifier. Only the code, which appears in Column 2 of the NCCI PTP edits, qualifies for a 59 modifier. Table 1 offers examples of code pairings.

(Retrieved from CMS)
 

In addition to the PTP (Column 1/Column 2) edits, the NCCI publishes Medically Unlikely Edits (MUEs). These indicate how many units of a given code on the MUE list may, when medically indicated, be covered by your Medicare Administrative Contractor (MAC) for the same patient on a single date of service (DOS).

Like other CPT codes, the skin biopsy codes have received MUE edits. This means that for a given date of service, if the number of billed units of a given code exceeds the MUE, the excess will automatically be denied by Medicare. Such non-payments may be appealed successfully to a MAC via a redetermination if the medical record confirms that biopsy numbers in excess of the MUE were both medically reasonable and necessary and were performed. See the table on the next page.

Now let’s apply all of this to real-practice, procedural coding situations.

Example 1: A patient comes in with multiple suspected basal cell carcinomas. You biopsy three separate lesions located on the right cheek, left neck, and right arm using the tangential technique. You also biopsy a nasal lesion clinically suggestive of a deeply infiltrating basal cell carcinoma using the punch technique. You report the procedures as CPT 11104, 11103 x3, with ICD-10-CM code D48.5 – Neoplasm of uncertain behavior.

Answer: Correct. It is prudent in this case to report all four biopsies with ICD-10-CM diagnosis of D48.5, neoplasm of uncertain behavior, indicating the final diagnosis was of uncertain morphology at time of obtaining the tissue sample, hence the need for the biopsy which will help determine the final diagnosis.

Example 2: You do an incisional biopsy of a suspected scalp lentigo maligna and destroy 10 actinic keratoses with liquid nitrogen spray. You submit CPT 11106 for the biopsy and 17000 and 17003 x9 for the actinic keratoses destruction.

Answer: Incorrect. According to the NCCI PTP table, 17000 destruction requires a modifier. Report the procedures appropriately as: 11106, 17000-59, 17003 x9.

Example 3: You have learned from the above example and are determined to do this right. You destroy eight actinic keratoses with liquid nitrogen and biopsy two separate clinically atypical nevi using the tangential technique. You submit CPT 11102 and 11103-59, for the biopsies and 17000-59, 17003 x7 for the freezing destruction.

Answer: Incorrect. Yow! Why is that? The NCCI stipulates that add-on codes do not merit a 59 modifier. That is why you will not find biopsy and other add-on codes paired in Column 2 of the NCCI PTP (Column 1/Column 2) listing. Avoid appending the 59 modifier to add-on codes, including the biopsy add-on codes 11103, 11105, and 11107.

In this case, the claim would be reported as: 11102 and 11103 for the biopsies and 17000-59, 17003 x7 for the freezing destruction.

Example 4: During the course of a Mohs surgery on the nose of a Medicare patient, you identify a probable basal cell carcinoma on the patient’s right cheek. You and the patient would like to avoid a separate visit for a biopsy. You perform a biopsy of the cheek lesion using the punch technique and submit CPT 17311, 17312 for two stages of Mohs surgery, and 11104-59 for the biopsy.

Answer: Correct. First, Medicare policy allows payment for same-day biopsy(s) of lesions unrelated to the Mohs surgically treated tumor. The patient record should stipulate the separate location of the lesion. What if you biopsy a lesion using the tangential technique immediately preoperatively to confirm qualification for Mohs surgery via a diagnostic frozen section in a patient lacking a preoperative biopsy? The good news is that Medicare allows coverage of both the biopsy and the diagnostic frozen section processing and reading. Appropriately report the preoperative biopsy as CPT 11102-59 and 88331-59 for the frozen section and reading.

Example 5: You perform three biopsies on three separate clinically deeply palpable tumors using the incisional technique and two biopsies of carcinomas atypical nevi on the right arm and back using the tangential technique. You submit CPT codes 11106, 11107 x2 for the incisional biopsies, and 11103 x2 for the tangential biopsies.

Answer: Correct. Appropriate hierarchical coding of the biopsies was followed. The MUE table was consulted, and it was determined that the MUE for additional incisional biopsies is 2, so it was not exceeded. The MUE for additional tangential biopsies is 6, so nothing worrisome there. The MUE for the first biopsy is always one since a primary code (11102, 11104, 11106) may only be used once per encounter regardless of how many different types of biopsies are done. In this exzample, 11106 is the primary code.

However, if some of the lesions are located in the same anatomical ICD-10-CM code grouping, then the payer may adjudicate some of the biopsies as “duplicate.” Stipulate the distinct locations in the “notes” section and be prepared to appeal if inappropriate payment denial were to happen. 

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