Coding Consult

How to code minor derm procedures

You can often earn reimbursement for both a procedure and an office visit when removing a skin lesion. Here are the rules to follow.

This probably happens to you regularly: A patient comes in for an office visit, and you discover a dermatological problem such as a mole, wart, or skin tag. You perform an excision, destruction, or biopsy right then and there.

Are you receiving proper reimbursement for this situation? "In most cases, when an E&M visit turns into a dermatology procedure, you should bill separately for the office visit and the procedure," says Barbara Cobuzzi, president of Cash Flow Solutions, a physician reimbursement company in Lakewood, NJ. "Append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E&M code."

Let's say, for example, that a 52-year-old woman presents to have her asthma checked. You discover a skin lesion on her back and do a biopsy immediately. You can bill for the biopsy (11100, biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and the appropriate E&M visit—in this case 99212 or 99213—with -25.

"The minor surgical procedure does not raise the level of the office visit, because it's considered separate," Cobuzzi says.

"A lot of third parties don't want to pay for the office visit separately for these types of visits,'' says Carol Sissom, senior consultant at Health Care Economics, a coding and practice management firm in Indianapolis. "So it's helpful to send the documentation for the office visit.''

You'll also want to use different codes if it's a new patient visit. For instance, a new patient presents, and at the beginning of the visit you find a skin lesion of 0.5 cm in diameter on the back of her neck. You shave it off. Most of the visit is spent performing this procedure.

Use 11305* (shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less) for the minor procedure and 99025 (initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) for the new patient visit.

"Reporting 99025 indicates that three components of a new patient E&M service were not provided, but that an abbreviated history was taken and the record was established for the new patient," says Kent Moore, manager of health care finance and delivery systems at the American Academy of Family Physicians in Leawood, KS.

"The coder would bill for only the dermatological procedure and not the E&M if the physician did not document the E&M or if the patient came in for a scheduled dermatology procedure," Moore says.

The greatest challenge in billing for E&M services and minor procedures is when the patient presents to have a skin lesion "looked at." The patient is not simply scheduling a checkup, nor is he coming in to have the lesion removed.

"The key here is that minor procedures, such as lesion removal, have an inherent E&M associated with them," Cobuzzi says. "For example, if a patient comes in to discuss a mole, and the doctor performs a biopsy of the mole, the E&M portion is included in the biopsy. You can code only for the procedure."

Under such circumstances, you can bill for a separate E&M with modifier -25 only if there is thorough documentation showing that the physician performed a totally separate procedure.

When both the office visit and procedure are billed, two separate diagnosis codes are helpful but not required. "However, it is more difficult to support the separate visit if you only use one," Cobuzzi says. "More and more private payers are not paying for a separate E&M visit when you have only one diagnosis code, even though correct coding says you don't have to have two if you use modifier -25."

For instance, a patient presents to have his Type II diabetes checked, and the doctor notices a dark mole on the patient's arm and performs a biopsy. Link 250.xx (diabetes mellitus) to the office visit code with modifier -25 appended, and link 216.6 (benign neoplasm of skin, skin of upper limb, including shoulder) to 11100.

Don't use two different diagnoses when a patient comes in to have a skin lesion looked at. For example, a patient has a bad itch on his back. You determine that it's a seborrheic keratosis and destroy it with cryosurgery. Use 702.1x (seborrheic keratosis) linked to the appropriate E&M code (with modifier -25 appended) and to 17000* (destruction [e.g. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g. actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion). Using the same diagnosis code for both is correct because the patient came in because of the itch and the surgery was performed to get rid of the itch.

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.

 

Coding Consult: How to code minor derm procedures. Medical Economics 2002;9:24.