Private Payer Resource Center

Skin biopsies and other procedures are often appropriately performed after an evaluation and management (E/M) service. Most payers expect modifier 25 to be reported with the E/M in those cases. The work involved in making the decision for the procedure is included in the fee for the procedure, and it is appropriate to code for both and get full reimbursement if the additional E/M work is unrelated to the decision to perform the procedure.

Many excision procedures for benign and malignant skin lesions result in defects that require a layered repair to meet the standard of care. Most insurance carriers recognize the medical necessity and separate nature of layered repairs. CPT descriptors specifically state that excisions only include simple (non-layered) closure. When both procedures are performed during the same session, the reimbursement for one of the procedures may be reduced by 50% because of the multiple procedure reduction rule. Some software edits inappropriately bundle excisions and repair procedures, misrepresenting one service as incidental to the other. If a dermatologist experiences such inappropriate bundling, an appeal to the Medical Director is advised.

Sometimes it is necessary for a Mohs surgeon to perform a diagnostic biopsy prior to Mohs surgery. AMA CPT Guidelines for Mohs Microsurgery specify that:

If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11102,11104, 11107) and frozen section pathology (88331) with modifier 59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery.

Most carriers recognize the modifier 59 and pay for such services; however, a few carriers still bundle the biopsy with the Mohs procedure.

Occasionally insurers try to implement policies to reduce payment for add-on codes, which is never appropriate. Codes designated in AMA CPT as Add-On codes are already valued as secondary procedures and are therefore exempt from the multiple procedure payment reduction rule (MPPR). Add-On codes are listed in AMA CPT with a ‘+’ symbol in front of the code and listed in Appendix D or in the Medicare Fee Schedule Data Base, (MFSDB) with a ZZZ global period.

Patch testing remains the gold standard and objective scientific method available to physicians to diagnose ACD. Improving the accuracy of diagnosing allergic contact dermatitis (ACD) is increased through appropriate and comprehensive use of patch testing to lessen both the morbidity and economic impact caused by this chronic skin disorder. In contrast to the limited and screening series patch test, comprehensive patch test encompasses a broader range of available allergens, allowing for greater diagnostic potential and improved patient outcomes.

Payers may inappropriately reduce reimbursement for evaluation and management (E/M) services by downcoding levels of service, applying incorrect bundling logic, or denying payment based on unsupported medical necessity or documentation assumptions. When E/M services are reported in accordance with CPT guidelines and supported by the medical record, payment reductions are not justified.