Coding lessons learned in 2022 — update on all of the common coding FAQs

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

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

2022 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 coding guidance to different dermatology coding scenarios/issues that were addressed during the calendar year.

Q: A Medicare patient presents with two biopsy-proven squamous cell carcinoma lesions. One lesion was located on the right shin and the other on the left shin.

The dermatologist performs destruction procedures on each lesion and reported the service with CPT code 17262 for each procedure. The second destruction code was appended with modifier 59. Unfortunately, the claim was denied.

How should this claim be reported to avoid claim denial?

A: The issue with this claim may be that the second procedure was reported with an incorrect modifier. Some payers, like Medicare, prefer that you append modifier 76 – repeat procedure when two of the same codes are reported for a procedure that is performed more than once by the same physician, to the same patient on the same date of service (DOS).

However, this may not be the case with private payers because some of them would rather the procedure be reported in units (e.g., 17262 x 2), without a modifier. Hence, we recommend that you check directly with the payer to verify their coding preference. See our article in DermWorld Coding Consult about getting paid for repeat procedural services.

Q: Under special dermatologic procedures, the AMA coding manual includes a code for actinotherapy using ultraviolet light. However, the code descriptor does not detail who can initialize the light therapy when narrowband UVB phototherapy treatment is performed by a registered nurse after the patient applies mineral oil to the skin lesions.

A: The light therapy treatment is typically provided by ancillary staff under the direct supervision of the dermatologist or non-physician clinician (NPC). As such, after the patient has applied the mineral oil to the lesion(s), the ancillary staff can put the patient in the lightbox and turn on the light following the dermatologist/NPC documented treatment instructions.

In this circumstance, the only service provided is phototherapy by ancillary staff. It is, therefore, appropriate to report CPT code 96900, Actinotherapy (ultraviolet light). CPT code 96900 is reported once per session. If actinotherapy is performed on different anatomical areas (e.g., hand, foot), CPT code 96900 should only be reported one time, regardless of the number of anatomical areas treated.

Note: CPT code 96900 – Actinotherapy (ultraviolet light) has no physician work included. The only RVUs available for 96900 include practice expenses and malpractice insurance.

Q: What is the appropriate CPT code to report for the removal of ingrown hair from a patient’s chin? Would CPT code 17999 – unlisted procedure, skin, mucus membrane and subcutaneous tissue be appropriate to report?

A: There is no specific CPT code to report for the removal of ingrown hairs. Because hair removal may sometimes be deemed a cosmetic procedure and not medically necessary, it is important to review the patient’s health plan benefits policy to determine if hair removal/removal of ingrown hair is a covered service. If approved, ask for specific guidance on which codes are acceptable to report the service by the payer.

It is always a safe bet to obtain pre-authorization before the service is provided and completion of patient financial consent to ensure the practice and the patient understand who is responsible for paying for the service should the claim be deemed not medically necessary and therefore denied.

Q: On day one, a patient is seen for evaluation and treatment of a benign lesion. The lesion is treated using the destruction technique (CPT code 17110). Five days later, the patient returns to the practice and presents for evaluation of proliferative vascular lesions that are treated using the destruction technique (CPT code 17108).

How is the procedure performed on day five reported to avoid claim denial as a bundled service?

A: Because the procedure on day five is performed during the global period of the original destruction of benign lesion procedure, it should be reported with a modifier to indicate that the destruction of proliferative lesions was performed during the global period of an unrelated procedure.

In this instance appending modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period usually does the trick and allows separate reimbursement for the service performed within the global period of an unrelated procedure (e.g., 17108 - 79).

Q: A patient is diagnosed with dystrophic nails and the dermatologist obtains nail clippings for the purpose of performing a KOH test. Is CPT code 11755 Biopsy of nail unit (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) appropriate to report this encounter?

A: According to AMA CPT coding guidance, CPT code 11755 is not intended to be reported when obtaining nail clippings or nail bed scrapings for purposes of performing a fungal culture, KOH preparation, stain or test, or PAS stain. These activities are part of the E/M visit involving the medical management of the nail condition.

Q: Before a scheduled vacation, the dermatologist contracts a substitute to cover and see patients during the primary (regular) dermatologist’s absence. How would the services provided by the fill-in physician be billed?

A: CMS allows dermatologists to use substitute physicians (previously known as locum tenens) and report services provided to their patients for the time the primary dermatologist is unable to see patients.

To report services provided by the substitute physician, the dermatologist or group practice will report the substitute physician services under the regular dermatologist’s name, NPI, and tax identification number along with a modifier Q6 which is entered in item 24d of the CMS-1500 claim form to indicate the service was provided by a substitute physician.

Note: Use and billing for substitute physician services using the regular dermatologist’s NPI and tax identification number is a Medicare-specific provision and it does not apply to private payers. We encourage you to contact the private payers you are contracted with for specific coding and reporting guidance for services rendered by substitute physicians.

More helpful information can be found at the DermWorld article Tenets for locums.

• During the Public Health Emergency (PHE), CMS has provided waivers that allow dermatologists to use the same substitute physician for an extended period — more than the allowed 60 calendar days if needed. This waiver will be removed once the PHE is over and the 60-day calendar day maximum will go back into effect.

Q: Two Mohs surgeries are performed on the same day — one on the right temple and the other on the right hand. The final size for the surgical site on the temple was 3.4 cm and the final size for the hand was 2.4 cm. Both defects are repaired with complex repair with a final repair length of 3.4 cm each. The medical record is appropriately documented and reported with the Mohs surgery codes and CPT codes 13131 and 13132.

A: The AMA CPT coding guidelines state that when multiple wounds are repaired, the lengths of the repairs in the same classification and from all anatomic sites that are grouped together into the same code descriptor should be added together and reported based on the total length of the repair.

For example, add the lengths of complex repairs to the trunk and extremities together and determine the total repair length. Do not add lengths of repairs from different groupings of anatomic sites (e.g., face and extremities) or different classifications (e.g., intermediate and complex repairs).

As such, the defects repaired during this encounter are both included in the same code descriptor indicating the anatomical location. Therefore, the defects should be added and a single repair code reflecting the total defect size will be reported with CPT code 13132 — Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm, based on the total length of repair for both anatomic sites.

Q: Is there a definition for retention suture(s) as it relates to a complex layered closure?

A: There is no official CPT definition of retention sutures. The classical definition of retention sutures is for abdominal surgery, with large loops of sutures placed through the skin and the full thickness of the abdominal wall.

During the code revision for intermediate and complex repairs, our dermatology physician experts referred to retention sutures when used in dermatology as those set back significantly from the line of closure, penetrating through the skin and subcutaneous space on both sides of the incision commonly in a horizontal mattress pattern with material under them so that they do not score the skin, and then tied.

Most of the time, retention sutures in dermatology are used to approximate skin that cannot hold buried/dermal sutures, meaning that a layered repair containing a dermal/subcutaneous layer of suturing cannot be done.

Q: Is there a CPT code I can use to report for laser hair removal performed on patients undergoing gender reassignment surgery?

A: Unfortunately, there currently is no National Coverage Determination for services provided for gender reassignment surgery. However, CMS is currently allowing MACs to cover gender dysphoria surgeries, which may include hair removal, on a case-by-case basis. Visit the CMS page for more.

Some other payers are already covering the procedure, but we recommend checking individual payer guidance for certainty.

There is also no specific CPT code to report laser hair removal for gender reassignment surgery. We recommend that before the service is provided, the dermatology practice contacts the payer directly for specific coding guidance.

Q: The dermatologist injected fluorouracil 500 mg to treat warts. How would this service be reported?

A: Currently, there is no J-code for fluorouracil less than 500 mg administered intralesionally. According to the CMS table of drugs (PDF), fluorouracil 500 mg is listed with the HCPCS code J9190 and administered intravenously (CPT code 96409 - 96416).

However, considering the alternative of reporting based on the intent of the procedure, which is to destroy the lesion using a chemical, we recommend considering the benign lesion destruction codes: 1711x - Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions (based on the diagnosis and number of lesions treated). In this case, one would not bill for the drug separately, as this is included in the procedure code.

Q: Can an E/M code 99211 or 99212 be reported when the dermatologist is not on the premises and does not see or interact with the patient, but staff (e.g., medical assistant (MA) or registered nurse) sees the patient, takes photos of a patch testing site to see if there is a delayed reaction for the physician to review at a later date, and performs suture removal from an excision site after the global period?

A: Although E/M code 99211 does not require the presence of a physician or other qualified health care professional in the exam room, it requires that the dermatologist or NPC be immediately available on the premises to assist the nurse or MA should they be needed.

On the other hand, E/M code 99212 includes the time and expertise of the dermatologist or NPC and cannot be reported for services rendered by ancillary staff including nurses and MAs.

To bill for services under the dermatologist or NPC’s NPI number, the dermatologist or NPC must either physically see the patient and provide service(s) or bill as ‘incident to’ if the NPC renders the service following the physician’s instructions. It is not appropriate to report services under the physician’s name if they did not personally supervise or provide the service.

Further, patch testing has a payment indicator 5 which means that the service is provided under direct physician supervision. This means the dermatologist or NPC must be on the premises and be readily accessible to provide guidance when needed for the service to be performed and reported.

Q: Is there a definition describing the difference between simple and complicated incision and drainage procedures (CPT codes 10060 & 10061)?

A: Unfortunately, the AMA does not provide specific guidance as to what is considered simple or complicated. In the December 2006 CPT Assistant FAQ on page 15, the AMA published the following:

Surgery: Integumentary System, 10060, 10140, 10180 (Q&A)

Question
Many of the incision and drainage codes (i.e., 10060-10140, 10180) include one code for simple procedures and one code for complicated procedures. Does the CPT code set define these terms?

AMA comment
No. The choice of code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.

Q: Can clinical staff (e.g., medical assistant, nurse) administer phototherapy treatment ordered by a dermatologist or NPC if the physician or NPC is not on site where the treatment is being administered to provide direct supervision? Does the dermatologist or NPC have to be on site for office-based phototherapy code 96900 to be reported?

A: CPT code 96900 and all of the other phototherapy codes have payment indicator 5. This means these are ‘incident to’ physician service codes. The rule to report these services are that there must be a qualified health care professional on site for the service to be reported. It does not have to be the primary dermatologist or NPC that ordered the treatment but can be any qualified health care professional who can be called to provide guidance and render care in case of an emergency.

In order to report any services to the insurer with the expectation of reimbursement, the service must be provided or directly supervised by a qualified health care professional (QHP). The AMA and CMS define a qualified health care professional as:

• Doctor of Medicine

• Doctor of Osteopathy

• Doctor of Podiatric Medicine

• Doctor of Optometry

• Doctor of Oral Surgery

• Doctor of Dental Medicine

• Doctor of Chiropractic

• Anesthesiologist Assistant (AA)

• Certified Nurse Mid-Wife (CNM)

• Certified Registered Nurse Anesthetist (CRNA)

• Certified Nurse Mid-Wife (CNM)

• Clinical Nurse Specialist (CNS)

• Clinical Social Worker (CSW)

• Nurse Practitioner (NP)

• Physician Assistant (PA)

• Physical Therapist (PT)

• Other potential QHPs: Athletic Trainer, Dietitian

MAs or RNs are considered ancillary or clinical staff and cannot render and report a service with the expectation of reimbursement from an insurer.

Some private payers may have different rules and guidelines. We implore you to check directly with them as well as review state laws for specific coding guidance that applies to phototherapy light treatment when a dermatologist or NPC is not available on-site during the treatment time or to determine if any waivers apply during the PHE regarding the incident to services.

Q: Is there coding guidance on how or when to report ICD-10-CM D48.5 Neoplasm of uncertain behavior of skin versus D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin?

A: The Academy coding guidance is based on the Current CDC ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines are the rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM coding manual.

It is important for all users to review the coding guidelines to ensure the code selection is made to its highest specificity.

The ICD-10-CM coding manual states to report D48.5 – Neoplasm of uncertain behavior of skin, when histologic confirmation has not been made, whereas D49.2 classifies neoplasms of unspecified morphology and behavior by site. The term ‘mass,’ unless otherwise stated, is not to be regarded as a neoplastic growth (see below).

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