Hot coding topics from the field

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, July 1, 2024

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

The AADA coding team responds to many inquiries from dermatology practices and the house of medicine on dermatology-related coding issues. The coding team compiles some of the most frequently asked questions to share with dermatologists and their staff.

The following Q&As are republished with permission from the American Medical Association CPT Assistant Editorial Board (AMA CPTA EB).

Q. A dermatologic surgeon performs a debridement of a necrotizing soft-tissue infection of the perineum, perirectal, and medial thigh areas, without muscle involvement. Would code 11004 be reported for this procedure if the muscle is not debrided?

A. Yes, report code 11004, Debridement of skin, subcutaneous tissue, muscle, and fascia for necrotizing soft tissue infection; external genitalia and perineum. Note that all of the elements included in the code descriptor need to be performed; otherwise, modifier 52, Reduced Services, would need to be appended to code 11004.

Q. A patient is seen by a dermatologist in the office. Two weeks later, the patient is admitted to the hospital by a physician other than the dermatologist, and the dermatologist is contacted for a consult. What would be the appropriate Current Procedural Terminology (CPT^®) code(s) to report for this scenario?

A. In this scenario, the dermatologist would report the appropriate consultation code (99242-99245), while the admitting physician would report the appropriate inpatient or observation care code (99221-99223). If the patient remains hospitalized, then an appropriate subsequent hospital inpatient or observation care code (99231-99233) may be reported.

Q. An established patient presents with a growing lesion on the nose. In addition, the patient reports multiple enlarging growths on the back and dense scaly lesions on a bald scalp. A suspected basal cell carcinoma on the nose is tangentially biopsied using the tangential/shave technique. In addition, the patient is reassured that the lesions on the back are seborrheic keratoses that do not require treatment. However, the patient was diagnosed with diffuse scalp actinic keratoses for which topical 5-fluorouracil cream treatment is prescribed and the treatment plan is discussed. Diffuse scalp actinic keratoses are diagnosed; topical 5-fluorouracil cream treatment is prescribed and the treatment plan is discussed.

A. Code 11102, Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion, would be reported for the biopsy. Code 99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making, would be reported with modifier 25 appended to indicate that a significant, separately identifiable evaluation and management (E/M) service was provided.

While the E/M associated with the suspected basal cell carcinoma is included in the global package for the skin biopsy code, the management of multiple enlarging growths on the back and the scaly lesion on the scalp may be reported as a separate E/M service.

Key points for reporting modifier 25

• Modifier 25 should only be used with E/M codes.

• Modifier 25 is not restricted to a specific level of E/M service.

• The E/M service provided must meet the criteria applicable to that service (i.e., medically appropriate history and/or examination, and MDM or total time on the date of the encounter within code parameters).

• CPT coding guidelines do not require different diagnoses for the E/M service and the additional procedure or service performed to be reported.

• Modifier 25 should not be used to report an E/M service that results in a decision to perform surgery (modifier 57 should be reported in this instance).

• Modifier 25 should only be used when the E/M service is significantly and separately identifiable from the procedure or other service performed on the same date.

• The significantly and separately identifiable E/M service(s) provided must be properly documented in the medical record.

Q. Two single-stage Mohs surgeries are performed on the same day — one on the right forehead and the other on the right hand. Both defects are repaired with a complex repair with a final repair length of 3.4 cm for the surgical site on the forehead and 2.4 cm for the repair length on the hand. The medical record is appropriately documented. Should the procedures be reported with the Mohs surgery codes (17311-17315) and complex repair codes (13131, 13132)?

A. For the first site, the Mohs surgery should be reported with CPT code 17311, Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks, and an additional unit of code 17311 with modifier 59 appended for the Mohs surgery on the second site. (Note that the defect sizes are not relevant for Mohs surgery.)

Reporting wound repairs depends on the site, size, and complexity of the repair. According to the CPT coding guidelines, when multiple wounds are repaired, the lengths of the repairs from the same classification (i.e., simple, intermediate, complex) and from each group of anatomic sites (i.e., all of the anatomic sites that are grouped together in a code) should be added together and the code reported should be based on the total length of the repairs. For example, the lengths of two complex repairs to the extremities (i.e., arms and legs) would be added together to determine the total repair length because they are in the same anatomical grouping for the code descriptor. Note that repair lengths from different groupings of anatomic sites (e.g., face and extremities [arms and legs]) or different classifications (e.g., intermediate and complex repairs) would not be added together.

As such, the defects repaired during this encounter (hand and right forehead) are of the same repair classification (complex) and are grouped together in the same code. Therefore, the lengths of the repairs for both the hand and the right forehead should be added together (i.e., 3.4 cm + 2.4 cm) to derive the total length of repairs for both anatomic sites (5.8 cm). Hence, code 13132, Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm, would be appropriate to report.

Coding for postoperative removal of sutures or staples

In 2023, coding changes were made to the CPT to allow for reporting of postoperative suture and/or staple removal, when appropriate. Two new add-on codes (15853, 15854) were established.

Below are the new code descriptors as well as a CPT overview of the intent and use for these new codes.

Removal of sutures or staples without anesthesia

There was a need to have codes to report practice expenses related to suture or staple removal for postoperative E/M visits after 0-day global period procedures. For 2023, two new add-on codes (15853, 15854) were established for reporting suture and/or staple removal in conjunction with an E/M visit.

These codes may be reported with an appropriate E/M service for any procedure that has a 0-day global period, and possibly for codes with XXX global period assignment if sutures or staples were placed. These new add-on codes do not have physician work relative value units (RVUs) assigned to them because they are practice expense (PE)-only (i.e., clinical staff time, disposable supplies, use of equipment).

Prior to 2023, there was no PE-only reimbursement code to report suture or staple removal at an E/M visit after a procedure with a 0-day or XXX global period assignment. Because codes 15853 and 15854 are add-on codes to be reported with an E/M code, no modifier should be appended to the E/M code.

Clinical example (15853)

A 60-year-old male, who is status post-hernia repair of a 3- to 10-cm defect, undergoes removal of sutures during a separately reportable office or other outpatient E/M service.

[Note: This is an add-on code. Consider only the work associated with removal of the sutures.]

Description of procedure (15853)

Clean the area surrounding the wound(s) with normal saline or soak if crusting inhibits access to sutures/staples. Remove the sutures or staples. Observe the wound line(s) for separation during the procedure. Obtain hemostasis with pressure as needed. Apply adhesive strips and sterile dressings as needed.

Clinical example (15854)

A 60-year-old male, who is status post-hernia repair of a 3- to 10-cm defect, undergoes removal of sutures and staples during a separately reportable office or other outpatient E/M service.

[Note: This is an add-on code. Consider only the work associated with removal of the sutures and staples.]

Description of procedure (15854)

Clean the area surrounding the wound(s) with normal saline or soak if crusting inhibits access to sutures/staples. Remove the sutures and staples. Observe the wound line(s) for separation during the procedure. Obtain hemostasis with pressure as needed. Apply adhesive strips and sterile dressings as needed.

Examples:

Q. A patient had a 3-cm biopsy-proven, atypical, pigmented nevus removed from her shoulder. Because of the tension across the wound, the physician decided to leave the sutures in for 14 days. The lesion-removal code reported (i.e., 11403) has a 10-day global period. When the patient returns on day 14 for wound assessment and removal of the sutures, would the physician report an E/M services code and suture removal code 15853?

A. No. Removal of sutures or staples not requiring anesthesia (list separately in addition to E/M code), may not be reported for removing sutures that were placed for a 10-day global procedure for any postoperative visit (during and beyond the global period) because suture removal is inherent to and included in the practice expense for all 10-day global codes when the sutures are placed. Therefore, an E/M service may not be reported on day 14 because this work occurred four days after the 10-day global period. In addition, code 11403, Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm, includes postoperative work to assess the wound and remove the sutures.

The following are some of the coding inquiries received by the AAD coding team and include coding guidance provided to dermatology practices.

Q. Can a patient’s personal history of skin cancer (Z85.82x) be categorized as a stable chronic illness under the E/M medical decision-making elements table, number, and complexity of problems addressed?

Effective Oct. 1, 2023, the CDC/NCVHS revised the coding guidelines (I.C.21, 8) Follow-up encounters to allow dermatologists to report dermatology patient follow-up encounters for patients with a history of malignant neoplasms using ICD-10-CM code Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm as the primary diagnosis code followed by an appropriate history of (Z85.82x) malignant neoplasm that was previously treated.

See DCC: ICD-10-CM diagnosis coding updates for 2024

A. Yes, the personal history of skin cancer (Z85.82x) can be categorized as a stable chronic illness under the E/M medical decision-making elements table, number, and complexity of problems addressed. According to the AMA definitions for the medical decision-making elements terminology, a stable chronic illness is defined as a problem with an expected duration of at least a year or until the death of the patient.

A patient with a history of skin cancer will need continuous dermatology skin exams and surveillance to ensure there are no reoccurrences of skin cancer. The surveillance is conducted continuously for the rest of the patient’s life. As such, continuous surveillance for skin cancer is considered a current problem being addressed or treated and because this is going to be performed for the rest of the patient’s life, it qualifies the personal history of skin cancer as a stable chronic illness.

Q. Which ICD-10-CM code is most appropriate to report for a skin biopsy that does not have a final histopathologic diagnosis code between D48.5 Neoplasm of uncertain behavior of skin and D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin?

A. In this circumstance, it is appropriate to report ICD-10-CM code D48.5 when final histopathologic diagnosis confirmation is not available. Our coding guidance is based on the CDC 2024 ICD-10-CM Official Guidelines for Coding and Reporting which supports that D48.5 - Neoplasm of uncertain behavior of skin when histologic confirmation has not been made/established.

• ‘Uncertain behavior’ identifies tissue that based on clinical examination and observation, is beginning to exhibit neoplastic behavior but cannot yet be categorized as benign or malignant. Additional or further testing is required.

• ‘Unspecified behavior’ identifies neoplasms of unspecified morphology and behavior based on documentation in the medical record. Similarly, additional or further testing is required.

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