Coding for Shave Removals Vs. Biopsies
- Volume 16 - Issue 6 - June 2008
- Posted: 9/4/2008 - 4:34pm
- 16186 reads
This quarterly feature series by expert on dermatology coding, documentation and reimbursement Inga Ellzey will focus on relevant coding issues that most dermatologists frequently encounter.
Q. What is the difference between a shave removal (CPT codes 11300 to 11313) and the biopsy codes (11100/11101)? I think that we might be incorrectly coding. My doctor bills 11100 when he removes moles for diagnostic purposes. However, I think these situations should be considered shave removals. What is your opinion?
A. It’s really quite simple. Carefully review the definition of a shave removal. The wording simply states, “removal.” That means the lesion was removed by shaving. A biopsy is when only a portion of a lesion, tissue, or skin is removed in order to obtain a diagnosis. Taking a portion of a lesion is not removing it.
Many dermatologists under-code removals of nevi (moles) by charging for a biopsy when, in essence, they are actually performing a shave removal.
Make sure that your operative note is consistent with what you charge. Don’t use terms such as a “shave biopsy removal” or “incisional biopsy” when you are actually doing a shave removal. A biopsy is a biopsy and a shave removal is just that, a shave removal.
You might be losing a lot of money if you consistently undercode for this procedure. Let’s review the fees for the two sets of codes.
Here, I’ll review a couple of scenarios so you can better understand how to correctly bill and how your reimbursement levels would differ based on which procedure you bill for.
Let’s say you shave removed two lesions on the back, and each one was 0.6 cm/d.
Shave Removal, Scenario 1. You would bill: 11301 and 11301. You would receive $79.90 and $39.95 (50% reduction for second lesion) for a total of $119.85. Biopsy, Scenario 1. If you billed the biopsy codes instead, you would get $87.60 and $28.57 for total of $116.70. This represents a loss of $3.15.
This may not seem significant, but the losses get worse when you get into areas of the neck, hands, face, etc.
Shave Removal, Scenario 2. If you billed 11306 and 11306, you would be reimbursed $83.79 and $41.89 (50% reduction for second lesion) for a total of $125.68.
Biopsy, Scenario 2. If you billed the biopsy codes instead, you would get $87.60 and $28.57 for total of $116.70. This represents a loss of $8.98.
If you removed three lesions of 11306, the difference would be $167.57 versus $144.74, which represents a loss of $22.73.
Now let’s review these coding scenarios for two lesions located on the face.
Shave Removal, Scenario 1. In this example, you would bill 11311 and 11311. Your reimbursement would be $91.41 and $45.70 for a total of $137.11.
Biopsy, Scenario 1. If you billed the biopsy codes instead, you would receive $87.60 and $28.57 for total of $116.70. This represents a loss of $20.41 on just two lesions.
Think of how many times a year you shave remove nevi or other benign lesions. Then compare the payments to those that you would receive if you billed biopsy codes only.
Keep the following in mind:
1. Only 2 biopsy codes exist — versus 12 shave removal codes.
2. The biopsy codes do not pay you more if you remove a lesion on the back versus a lesion on the face.
3. If the lesion (e.g., nevi, seborrheic keratosis, and warts) is larger than 0.5 cm/d, then the payments are more in 7 out of the 12 codes versus the 2 biopsy codes. In other words, you make more money billing 11302, 11303, 11307, 11308, 11311, 11312 and 11313 than 11100.
4. If you bill more than one shave removal, you make more money for the second lesion billing the 113XX series than you do 11101. For all 12 codes, you get paid more billing this way.
Let’s take a look at what I mean.
When you bill a second lesion using the 113XX series, you get paid more based on the size and location of the lesion — compared to performing a biopsy, which pays the same regardless of location.
Below I have taken the 12 codes and reduced them by 50% and compared the fees to the second biopsy code 11101. The bottom line:
1. 7 out of 12 times (or 58% of the time), you will make more money billing 113XX code for the first lesion versus 11100.
2. 100% of the time, you will make more money if you remove more than one lesion on the same date of service.
3. The losses are significant when the lesions are larger than 0.6 cm/d and performed on the face.
4. Use ICD-9 code 238.2 when billing the shave removal codes to show the lesion met medical necessity criteria such as painful, bleeding, suspicious of skin cancer, edematous, erythematous, or inflamed.
Q. We want to know if we are correctly billing frozen sections. These are not billed with Mohs, but for other procedures. We have a dermatopathologist who works for our group, and we have a full C.L.I.A.-certified lab on the premises. So please advise as to whether we are billing frozen sections using CPT codes 88331 and 88332 correctly.
Scenario 1. Three separate biopsies were performed on the same date of service, but from three different anatomical locations. We performed frozen histology on three specimens and billed 88331 at three units. Is this correct?
Scenario 2. We excised a squamous cell carcinoma. The dermatopathologist sectioned this one tissue specimen into three separate sections and stained each. We billed 88331 at one unit and 88332 at 2 units. Is this correct?
A. You are correct. When you bill frozen sections for different specimens (e.g., different anatomical sites), you bill CPT code 88331 at one unit for each separate lesion. (Be sure to bill on one line of the claim form in units, not on separate lines with modifier 76 or 59). If you are cutting one specimen from one anatomical location into smaller sections, then you bill 88331 for the first sectioning and 88332 at one unit for each additional section cut. And don’t forget to charge for the special stains in addition to CPT codes 88331 and 88332.
Q. I thought that the destruction of malignant lesions codes (e.g., 17260 to 17286) were bundled into the destruction codes of Actinic Keratosis (e.g., 17000, 17003 or 17004). I have been putting modifier 59 on the 17260 to 17286 codes and Medicare has been denying these codes. What am I doing incorrectly? Do I have to have the patient come back and do these destructions on different dates of service in order to get paid?
A. Every 90 days, Medicare’s Correct Coding Initiative changes significantly. Some versions have huge changes that affect dermatology. In the past 18 months, we have seen huge bundling changes. It is important that you get on an update service that automatically sends you the latest version.
Most non-Medicare insurance carriers follow the same edits that Medicare does with respect to bundling, so your denials won’t be just for Medicare claims; you’ll get denials from most of the major carriers as well.
Most carriers now have edits that will deny a CPT code if it has modifier 59 attached when that modifier is not required. Obviously, it will deny if modifier 59 is needed, but it will also deny if modifier 59 is attached when it is not required.
In your question, the 2 sets of codes you referred to, 17260 to 17286 and 17000 to 17004 are not bundled with one another. You can bill any combination of those 21 codes and no modifier is required. However, if you add any other surgical codes into the mix, such as 17110 or 17111, then all the rules change and you’ll have to access the current CCI version since there are no consistent patterns.
Just for your information, the Inga Ellzey Practice Group has new software that incorporates the current versions of Medicare’s CCI. The new DermCoder software now has a new feature called QuickCheck that allows you to check up to 6 CPT codes at once (and in any order) to see if modifier 59 is needed and if it is, on which CPT code it should be appended.
Q. Can I get paid for giving an injection (e.g., subcutaneously or intramuscularly) and also get paid for the E/M visit on the same date of service. My billing staff tells me that most carriers will only pay one or the other? Any insight?
A. Here is another example of the Medicare Correct Coding Initiative edits that are not only used by Medicare but also by most commercial carriers as well. CPT code 90772 (the injection code) is bundled with all E/M visit codes. So you must place modifier 25 on the E/M visit when billing the injection code (e.g., 90772) to show that you have done and documented a significantly and separately identifiable evaluation and management service. You do not need separate diagnoses in order to bill both services.
Just for your information: When an E/M visit is bundled in the CCI (e.g., it appears in column II of the bundling tables), you do not use modifier 59. You must use modifier 25 instead of modifier 59. This applies to all codes that start with 992XX, 993XX, and 994XX. Modifier 59 is never used on E/M visits.
Ms. Ellzey, President/ CEO of the Inga Ellzey Practice Group, Inc., in Casselberry, FL, is an expert on dermatology coding, documentation and reimbursement. She has more than 35 years of experience in the field of dermatology and is also the CEO and founder of two nationwide dermatology billing services.