Coding lessons learned from frequently asked questions in 2023

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, December 1, 2023

Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.

2023 has come to a close and the coding team has fielded many coding inquiries from members. In this article, the coding team reflects on the lessons learned by addressing and providing recommended appropriate coding guidance to different dermatology coding scenarios/issues that were addressed during the calendar year. 

Question:

How and when can we report the newly established suture removal code(s)? Should we bill these new codes when we bring the patient back to the office for removal of sutures placed during closure of a wound defect?

Answer: The AMA created the following suture removal CPT^® codes that can be reported, in addition to a separately identifiable evaluation and management (E/M) service, when sutures are removed after a zero-day global procedure:

15851 Removal of sutures under anesthesia (other than local), other surgeon

15853 Removal of sutures or staples not requiring anesthesia  (List separately in addition to E/M code)

15854 Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code)

Specifically, CPT codes 15853 and 15854 are appropriate for reporting suture removal (not requiring anesthesia or sedation) in the office or other outpatient sites from a defect with zero global period when a separately identifiable E/M code is also reported on the same date of service (DOS). Codes 15853 and 15854 are add-on codes and can only be reported with E/M services codes to account for the practice expense involved in the suture and/or staple removal that is not inherent in the E/M codes.

As such, these codes are only reportable with an E/M service code. Please note that modifier 25 is not necessary because these codes are designed to only be reported with an E/M code and cannot be reported as first-listed codes.

CPT code 15853 was established to report for suture or staple removal not requiring anesthesia and Code 15854 was established to report suture and staple removal not requiring anesthesia. 

Question:

10 days following a punch biopsy (CPT 11104) or an incisional biopsy (CPT 11106), the patient comes in for a separately identifiable reportable office visit or other outpatient evaluation and management service to examine a newly identified lesion. During the encounter, suture(s) from the biopsy site are removed, pathology result(s) are discussed with the patient, and a plan of action is formulated based on the clinicopathological findings. 

You report an appropriate E/M code for the evaluation and management of newly identified lesion(s) and CPT code 15853 for the suture removal.  

Answer: Correct. It is appropriate to report the suture removal service with an appropriate E/M service code for this encounter. It is important to note that according to AMA CPT coding guidelines, CPT 15853 is an add-on code that can be reported only when a separately identifiable E/M service is performed and reported on the same date of service (DOS). 

Question:

10 days following a punch biopsy (CPT 11104) or an incisional biopsy (CPT 11106) the patient comes in for suture removal. The physician assistant (PA) removes the sutures and schedules the patient to see the dermatologist to discuss the pathology results and action plan. The PA reports CPT 15853 for the suture removal.

Answer: As previously discussed, CPT code 15853 is an add-on code and can only be reported when an appropriate E/M service is also performed, documented, and reported on the same DOS.

Based on the documentation provided, it would not be appropriate to report the suture removal code 15853 for this encounter because the patient was brought back specifically to have the sutures removed and a separately identifiable E/M service was not performed nor documented.

Question:

12 days following a wide excision, the patient comes in for suture removal and pathology results. The dermatologist discusses the results confirming an atypical pigmented lesion, describes a long-term follow-up plan, self-monitoring, and the need/not for any lab/imaging studies. The sutures are removed, an excision for residual margins is performed, and the defect is closed using the appropriate repair. The patient is reminded to schedule a three-month follow-up appointment.

CPT code 15853 is reported for the suture removal and an appropriate E/M code for the discussion and action plan as well as the appropriate CPT codes for the excision and repair procedures.

Answer: Incorrect. CPT code 15853 is not reportable for this encounter because the valuation for integumentary benign and malignant excision codes includes postoperative wound assessment and suture removal practice expenses for all 10-day global procedures. 

Consequently, suture removal, at any time, following a 10- or 90-day global procedure is not separately reportable using CPT codes 15853 or 15854. Discussion of pathology results and the decision to excise additional margins are included in the excision code for this encounter.

Question:

We recently received a letter from Medicare titled, “Targeted Probe and Educate.” What should I do to prepare for such a request?

Answer: The main goal of a Targeted Probe and Educate (TPE) request is to help dermatologists quickly improve their billing error rate by working in person with their Medicare Administrative Contractors (MACs) to identify coding and billing errors and render corrective actions. This targeted education is what makes this type of audit different from all other audits. 

When selected for a TPE review, the dermatologist may have a total of up to three rounds of review. A TPE review round involves the review of 20-40 claims per dermatologist, item, or service. The MACs are limited to a 40-chart request and a service-specific review based on Medicare payer data analysis of claims submitted by the dermatologist(s). 

Depending on the outcome of each round of review, the local MAC personnel will provide “one-on-one” education directly to the dermatologist(s) to help them quickly improve coding and documentation accuracy to help reduce claim denials and appeals. The dermatologist(s) are offered individualized education based on the outcome of the MAC review. Many common errors are simple — and may include missing a physician’s signature — and can easily be corrected during the first round of review.

If there is no improvement shown by the end of the third review, the local MAC personnel will provide instructions on the next steps for the dermatologist, which may include referral to the Recovery Audit Contractor (RAC), or depending on the severity of the error, dismissal from participating in the Medicare Fee-For-Service program.

For more information, review the Derm Coding Consult article ‘CMS TPE reviews are now in full swing,’ which provides details on the process. 

Question:

Should we be reporting the JZ modifier for our Kenalog injections as indicated in the Medicare “No waste” policy?  

Answer: Modifiers JW - Drug amount discarded/not administered to any patient and JZ - Zero drug amount discarded/not administered to any patient are used to report discarded amounts for drugs separately payable under Medicare Part B that is supplied in single-dose or single-use containers only. 

Coding guidelines require billing for injectable drugs to be reported with the drug code that reflects the dose on the bottle (e.g., triamcinolone acetonide [Kenalog] 40 mg is reported with J3300). If the amount of the drug injected is less than the HCPCS code dosage (or billable unit), one would bill this as 1 unit with the amount of the uninjected dose reported as waste with modifier JW. 

For example, 25 mg of triamcinolone acetonide is less than the 40 mg in the vial. In this case, your claim is reported as follows:

J3300 (injected 25 MG)

J3300 – JW (discarded 15 MG)

For more information on billing for unused drugs and biologics, please review Chapter 17 of the Medicare Claims Processing Manual - Drugs and Biologicals, Section 40.

Question:

Some payers are denying, even after appeal, reimbursement for CPT^® codes 14000-14302 stating that the documentation does not support the procedure coded.

Answer: Flap documentation wording found in Chapter III of the Integumentary System, Section H.1, page 9, Repair and Tissue Transfer of the National Correct Coding Initiative (NCCI) policy manual was recently revised by CMS to include the statement that tissue transfer and rearrangement require that adjacent tissue be incised and carried over to close a wound or defect. As a result, payers are now expecting dermatologists to include, as part of the tissue transfer documentation, that tissue was transferred as part of the procedure.

The Academy is encouraging dermatologist to update their templates and include either of the following statements in their medical record documentation to avoid inadvertent claims denials:

Example wording: 

A flap was raised and transposed (carried over) to cover the surgical defect… OR

Adjacent tissue was incised and carried over to close the defect in the following manner.

Question:

An established patient presents for his annual skin examination pursuant to a history of basal cell skin cancers, squamous cell skin cancers, and melanoma. A complete skin examination is performed. No other concerns are identified today. Sun protection, including the use of broad-spectrum SPF-15 or higher sunscreen and self-skin exams, are recommended treatments. The patient is advised to follow up in one year or if he sees any changes.

How would this encounter be reported effective Oct. 1, 2023?

Answer: The new ICD-10-CM coding guidelines effective Oct. 1, 2023, and going forward now allow dermatologists to report follow-up encounters for patients with a history of malignant neoplasms who do not have any other presenting problems.

The follow-up encounter code Z08 — Encounter for follow-up examination after completed treatment for malignant neoplasm — is reported as the primary diagnosis code, followed by the appropriate personal history of malignant neoplasm code with the appropriate E/M code. 

For example, this encounter would be reported as follows:

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

Z85.820 Personal history of malignant melanoma

Z85.828 Personal history of other malignant neoplasm of skin

*The F/up encounter code is listed first, followed by the appropriate personal history code(s).

Question:

A 50-year-old established male patient presents for his annual skin examination pursuant to a history of squamous cell carcinoma (SCC) on the right forehead treated five years ago. He has no concerns today apart from a few scattered brown spots on the trunk that end up being benign nevi and seborrheic keratoses.

A complete skin examination is performed, and diagnoses for the visit include benign nevi on the trunk, seborrheic keratoses, lentigines, and a history of SCC. Sun protection, including the use of SPF-15 or higher sunscreen, and self-skin exams are recommended treatment plans. How would this encounter be reported effective Oct. 1, 2023?

Answer: The encounter would be reported as a problem visit. In addition to the history of skin cancer, the patient in this scenario presents with two or more self-limited minor problems (benign nevi and seborrheic keratoses) which qualify this element as low complexity.

The example recommends the use of OTC broad-spectrum sunscreen which qualifies for the risk of complications and/or morbidity or mortality of patient management as low. There is no data reviewed. Therefore, an appropriate E/M service code would also be reported.

For example, this encounter would be reported as follows:

D23.5 Other benign neoplasm of skin of trunk

L82.0 Inflamed seborrheic keratosis

Z85.828 Personal history of other malignant neoplasm of skin

*The problems identified during the encounter are listed first, followed by the personal history of malignant neoplasm code.

Question:

How can I report flap surgical debulking that was incised, debulked, and repaired in a layered fashion performed outside the global period of a cheek-to-nose interpolated repair?

Answer: There is no longer a code to report scar revision since it was deleted as part of the requirements for complex repair service. Further, the CPT coding guidelines require that for one to report an intermediate repair, the repair must include repairing of wounds that, in addition to simple repair, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. It also includes limited undermining (defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect).

Based on the documentation provided, this encounter included a layered closure and may be appropriately reported as an intermediate repair.

However, if complex repair criteria are met via exposure of cartilage or the line closure being along the nostril rim, or if extensive undermining was performed and documented, then a complex repair could be reported.

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