Common coding questions: Answered

By Alexander Miller, MD, April 1, 2020

Over the last several months, I have been asked a variety of questions pertaining to some specific coding scenarios. The Academy coding staff and I have found that when one or two people formally ask a question, there are typically many more who wonder the same, but have not asked. The following offers answers to several common coding questions.

Removal of skin tags

Question: I removed 11 skin tags by snipping them off and then electrodesiccated seven more. Should I be reporting CPT® code 11200 twice, since two different removal methods were used?

Answer: A total of 18 skin tags were removed/destroyed via a combination of two modalities described in the CPT: “Removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction or combination of treatment modalities.”

All skin tags removed by any combination of the listed treatment modalities should be summed, and the appropriate CPT code should be reported. The removal of 18 skin tags should be reported with CPT code 11200 for the first 10 tags and code 11201 for the additional eight skin tags.

11200: Removal of skin tags, multiple fibrocuta-neous tags, any area; up to and including 15 lesions

+ 11201: each additional 10 lesions, or part thereof
(List separately in addition to code for primary procedure)

Skin tags removed with the “shave removal” technique (using a scalpel or flexible blade) should also be reported with CPT codes 11200, 11201 (CPT Assistant, November 2002).

Question: Fourteen small skin tags were frozen with liquid nitrogen. Is CPT code 17110 appropriate to report?

Answer: No. Although the introductory language to the “Removal of Skin Tags” section does not mention cryotherapeutic destruction of skin tags, the definition of CPT code 17110 states: “Destruction (e.g., cryosurgery) of benign lesions other than skin tags or cutaneous vascular proliferative lesions.”

Consequent to the code descriptor for benign lesions destruction section, liquid nitrogen ablation of skin tags defaults to the removal of skin tags CPT codes 11200 and 11201 (CPT Assistant, August 2009).

Biopsies and shave removals

Question: The CPT illustrates a tangential biopsy (11102, 11103) as being done with a scalpel, but the shave removal codes (11300-11313) picture a flexible blade. In order to satisfy the coding criteria, should I use the illustrated instrument for each of the two types of procedures?

Answer: Absolutely not. The illustrations are of two possible instruments and techniques that can be used for sampling or removing lesions. The choice of instrument is at the operator’s discretion. The tangential biopsy introductory language description lists “a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel or curette” as potential tissue sampling tools. Similarly, the “Shaving of Epidermal or Dermal Lesions” introductory paragraph specifies a technique of removal: “transverse incision or horizontal slicing to remove epidermal and dermal lesions” but does not specify the cutting instruments that would be used to accomplish the feat. Thus, the sharp blades that may be used are not exclusive to the given examples and illustrations. For example, there are instances in which scissors, which are composed of sharp blades that meet, are the preferred cutting instrument.

Question: My EHR pops up CPT code 69100 whenever I biopsy the ear, regardless of the method of biopsy (tangential, punch, or incisional). Is this a proper choice?

Answer: CPT code 69100 is correct. The CPT has retained all previously existing site-specific biopsy codes, such as for nail unit (11755), lip (40490), penis (54100), vulva or perineum (56605, 56606), and ear (69100). These codes are technique agnostic and anatomically specific, meaning that they should be reported regardless of the biopsy technique (tangential, punch, or incisional) that is used if the biopsy is performed in the appropriate anatomic location.

Excision and destruction, eyelid

Question: I sharply excised with scalpel an irritated nevus located internal to the eyelid lash line and left the site to heal by secondary intention. Should I report the service as a shave removal (CPT 11310-11313) or a benign excision (CPT 11440-11446)?

Answer: The CPT instructs one to select a code that most appropriately describes what was done. In this case, although one may contemplate reporting a shave removal or a benign excision of eyelid code, the most specific descriptor is CPT code 67840, “Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure.” Consequently, CPT code 67840 should be reported.

Question: If a benign lesion located on the lid margin is destroyed with curetting and/or electrodesiccation, should it be reported with CPT code 17110, destruction of benign lesions?

Answer: No. CPT code 67850, Destruction of lesion of lid margin (up to 1 cm) best specifies what was done. Note that this code, based on the anatomic location of the lesion, is to be used irrespective of whether a lesion is benign, premalig-nant, or malignant. Destruction of lesions located on the skin of the eyelid should be specified with an appropriate integumentary premalignant (17000-17004), benign (17110, 17111), or malignant (17280-17286) code.

Complex repairs

Question: A Mohs excision of a scalp tumor penetrated through galea aponeurotica and exposed skull bone. Following an extensive subgaleal undermining, the site was closed linearly with stapling. Since bone was visualized and extensive undermining was done, does this qualify as a complex repair?

Answer: No. The CPT requires that criteria for intermediate repair be satisfied before any additional, complex repair qualifiers are applied. For dermatologic surgery, that typically means that a layered repair must be done as a component of a complex repair. In the above case only a single layer closure (stapling) was done and, as such, does not meet the complex repair coding criteria.

Flap/adjacent tissue rearrangement

Question: I repaired a nasal surgical defect with two distinct flaps: one an advancement flap, and another a transposition flap. As I did two separate flap repairs, I billed CPT 14060 for the advancement flap repair and 14060-59-76 for the transposition flap repair. Is that correct?

Answer: Incorrect. The flaps involved a repair of one anatomical billing unit, the nose. Consequently, the area of the defect plus that of the raised flaps should be summed to generate one code. For example, if the area of the defect is 4 sq. cm, the area of one flap is 6 sq. cm, and of the other, 4 sq. cm, one would submit one CPT code for the 14 sq. cm adjacent tissue rearrangement repair: 14061 (CPT Assistant, July 2008).

Question: I excised a basal cell carcinoma from the right forehead and another basal cell carcinoma from the left temple. I repaired each defect with a separate advancement flap, with the forehead repair measuring 7 sq. cm and the temple repair measuring 5 sq. cm. Should I sum the adjacent tissue rearrangement repairs and report CPT code 14041, or should each repair be reported individually with CPT code 14040?

Answer: Although the repairs were in the same CPT code 14040 anatomical billing unit (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet), the repairs were distinct and non-contiguous from each other. Therefore, each repair should be reported individually.

The challenge is in how to specify the distinctness of the repairs, since the same CPT code would be used for both. One could append a 59 modifier to the second repair. However, for Medicare patient billing, that may not suffice to distinguish them as separate services. Consequently, for Medicare patients one should append a 76 modifier (“Repeat procedure or service by same physician or other qualified health care professional”) to one of the 14040 CPT codes.

Additionally, in the notes section of the billing, one would be wise to specify the distinctness of the two procedures. Even so, one of the claims may be rejected by the payer and would then need to be appealed.

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