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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
A skin lesion usually presents as a visibly noticeable defect on the skin surface. It can be a raised discolored area or open weeping ulceration. Sometimes coders may have questions when it comes to selecting a lesion excision code from the integumentary section versus a tumor excision code from the anatomical area in the musculoskeletal system section. Here are a few different scenarios to help clarify these points.
When a lesion is visible on the skin surface and the physician excises it in an elliptical fashion, then the coder should report a code from the integumentary section based on the greatest diameter of the lesion with the most narrow margins necessary for excision. Simple repair is included in the excision code while intermediate and complex repairs can be additionally reported. Too often when the lesion size and margins are not listed in the operative report the coder will take the largest sized listed on the pathology report and use that size for coding, which is incorrect. A physician query should be initiated to obtain the proper size. After all, doesn't a physician need these measurements for coding also?
The next scenario is where many coders get tripped up. The patient may present with a bump or mass, and the physician has to dissect down to the mass in order to remove it. Since the mass wasn't present on the skin surface, should the coder report an integumentary code or a tumor code? According to the Aug. 2010 CPT Assistant, epidermal or pilar cysts can originate in the dermis (not on the skin surface) and extend into the subcutaneous tissue, but these types of cysts are not tumors so a code from the integumentary system should be selected. When a mass excision has been performed, verify whether or not the mass was a cyst or an actual tumor and this will help with the correct CPT code selection.
The same methodology would apply to lesions of the tendon sheath or joint capsule. When we talk about subfascial digital tumors, they are defined as tumors that are involved with tendons, tendon sheaths or joint capsules. Consider the following example: The physician removes a mass off of the superficialis tendon of the finger. If the mass was a ganglion, then the coder should report 26160 – Excision of lesion of tendon sheath/joint capsule, hand/finger. However, if the pathology report returned a finding of giant cell tumor, then the coder should report 26113 or 26116 – excision of a subfascial tumor based on its size of 1.5cm or greater or less than 1.5cm. Remember that with tumor coding, complex repair can be added as an additional code when that type of closure is performed.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
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