In the June 2015 issue of The Dermatologist, dermatologic procedures with zero-day global periods were discussed. This article (Part 4 in the series) will discuss procedures with 10-day global periods.
CPT Codes with 10-Day Global Periods
The majority of dermatology office procedures are considered minor and have an associated 10-day global period, which begins the day after the procedure day. If another procedure or office visit occurs within the 10-day global period, the bill will need appropriate modifiers in order to ensure reimbursement.
Shave, or incisional, biopsies can sometimes be misinterpreted as shave removals. Shave biopsies by definition should remove a piece of a lesion for diagnostic purposes, while a shave removal should remove the entire lesion for therapeutic purposes (Table 1).
A shave removal should only reach the epidermis or dermis and should not extend into the subcutaneous fat. If a shave removal does extend into subcutaneous fat, this would be considered an excision. Many physicians will not submit a Current Procedural Terminology (CPT) code for shave removals until the pathology report indicated clear margins and confirms diagnosis. Shave removals should be performed only for malignant lesions to ensure reimbursement. If a lesion removed via shave technique is benign, the appropriate CPT code would be 11100 even if the margins are clear. Shave removals typically reimburse at higher levels than the biopsy CPT codes. The CPT codes used for shave removals are based on the anatomic location and the diameter of the shave, which typically includes both the lesion diameter and a margin of clinically normal appearing tissue.
Skin tag removals have a separate CPT coding series from other benign removals or destructions. The CPT codes for skin tags are 11200 for up to 15 lesions, and 11201 for each additional 10 skin tags. These codes are independent of skin tag size, anatomic location or method of removal. Typical removal techniques can include cryosurgery, shave technique or snip removal. These CPT codes include any supplies used during the procedure. Cryosurgery of skin tags fall under this series of CPT codes and therefore it would be incorrect to use the 17110 CPT series. Many insurance companies will not reimburse for these CPT codes unless there is documentation to show the skin tags are inflamed or irritating to the patient. The 11201 code can use a quantity modifier if the number of removed skin tags is more than 25 in total. For example, if a provider removes 30 skin tags on a patient, the submitted CPT codes would be 11200 (for first 15 lesions) and 11201 + 2 modifier (for the second 15 lesions).
Intralesional injection CPT codes have 10-day global periods and do not include the medication being injected. Dermatologists often use these codes for Kenalog injections or Candida antigen injections for wart treatment. The CPT codes for injections are 11900 for up to 7 lesions and 11901 for 8 or more lesions. The provider should document either 11900 or 11901 per visit based on total number of injections. These codes do not require a quantity modifier. Similar to other procedures discussed in this section, the injection CPT codes include pertinent history, discussion of the procedure, consent and postoperative care. A supply code for the injected medication should also be submitted. These supply codes are called “J codes” and the J code for triamcinolone is J3301. The code J3301 represents 1 cc of triamcinolone 10 mg/cc concentration. A quantity modifier can be used with this J code to indicate how many units of triamcinolone or Kenalog are injected. For example, injection of 1 cc of Kenalog 40 mg/cc would be coded as J3301 + 4 units. Injection of 2 cc of Kenalog 10 mg/cc would be coded as J3301 + 2 units.
Cryosurgery is used in dermatology to treat benign, premalignant and malignant lesions. There are 3 different CPT series for each of the 3 above mentioned categories, and all destruction procedures have a 10-day global period. The cryosurgery codes, similar to skin biopsy codes, include pre-operative pertinent history, discussion of procedure, consent, supplies and postoperative wound care and instructions. Table 2 lists the CPT codes for benign and premalignant lesions. The premalignant cryosurgery codes are highly utilized in dermatology and are meant for treatment of actinic keratoses (AK). For the first AK, the CPT code is 17000, and for AK number 2 through number 14, the CPT code is 17003. The code 17003 needs a quantity modifier to indicate how many additional AKs were treated. For example, if a patient has 7 AKs treated with cryosurgery, the provider would bill 17000 for the first AK and 17003 + 6 for the remaining 6 lesions. If a patient has 15 or more AKs treated in a visit, the code 17004 is only used. The provider should never submit both 17000 and 17004 for the same procedure. The 17004 code does not require a quantity modifier. The benign cryosurgery codes are typically used for lesions such as plantar warts, inflamed seborrheic keratoses, flat warts and molluscum. The same CPT codes are used for other methods of benign lesion destruction such as curettage and electrodesiccation or chemical destruction. Only 1 benign destruction code should be submitted per clinic visit, depending on the number of lesions treated. These codes do not require a quantity modifier. For example, if a patient has 17 molluscum treated during the visit, the provider would submit a 17111 code only, with no quantity needed.
Malignant destruction codes are more complicated and depend on the size and anatomic location of the lesion. These destruction codes, analogous to benign destruction codes, can be used for treatment via cryosurgery, curettage and electrodesiccation or destruction via chemical methods (Table 3). Remember that this series of codes does not include shave removal techniques as discussed earlier. Determining the lesion diameter is controversial as the CPT guidelines do not specifically state at what point during the procedure the diameter should be measured for coding purposes. Many physicians will measure the clinically visible lesion prior to the procedure and the diameter of the defect after the procedure, and choose the CPT code based off of the second diameter. These malignant destruction codes include a biopsy component so a provider should never code for both a skin biopsy and a malignant destruction of the same lesion on the same visit.
Skin excisions are defined as surgical procedures which create a defect to the level of the subcutaneous fat and remove a lesion with a margin of clinically normal tissue. Skin excisions have a 10-day global period and can be repaired by a variety of different closures. The CPT codes for skin excisions are based on benign versus malignant diagnosis, anatomic location and diameter of the excision (Tables 4 and 5).
The diameter is calculated by measuring the diameter of the lesion and the margin on either side of the lesion. For example, the diameter of an 8 mm wide basal cell carcinoma with 4 mm margins would be: 8 mm + 4 mm + 4 mm for a total diameter of 16 mm or 1.6 cm. Skin excision codes, like other procedure codes, include pertinent history, pre-operative preparation, consent, the excision tray and supplies and postoperative care.
Documentation of an excision should include the following for proper reimbursement: lesion type (benign vs malignant), indication (not absolute but helps coverage for benign lesions), lesion size and anatomic location, size of defect, length of closure and need for layered closure if performed.
Other items that are not required for reimbursement but are recommended to be included in documentation: consent, type and amount of anesthesia, type of suture used, type of bandage applied and wound care instructions.
Most skin excisions will be repaired using a layered linear closure, also known as an intermediate closure. This type of closure indicates that dermal internal sutures are used to close the defect, and the superficial skin is closed either with sutures, staples, surgical glue or adhesive tape.
Intermediate closures by definition should not include retention or pexing sutures or extensive undermining. If the closure requires these components, it would be considered a complex linear closure. The CPT codes for intermediate linear closures are based on anatomic location and the length of the closure (Table 6). Single layer closures with extensive debridement can also be considered intermediate closures, but this scenario is not commonly encountered in dermatology. If 2 excisions are performed on the same anatomic subgroup during the same procedure visit, the lengths of the 2 excisions can be added together and 1 repair code submitted for the total combined excision repair length.
Occasionally dermatologists will perform an incision and drainage (I&D) of an abscess, furuncle or carbuncle. There are several CPT codes associated with this type of procedure. The CPT code 10060 is I&D of an abscess, including a carbuncle, hidradenitis suppurativa lesions, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia. This code is for single or simple I&D and includes associated surgical supplies. The CPT code 56405 is for I&D of an abscess in the vulvar area specifically. CPT code 10120 is for incision and removal of a foreign body in the subcutaneous tissue, such as a splinter for which removal necessitates an incision.
The next article in this series on 90-day global periods and proper coding of miscellaneous procedures in a future issue of The Dermatologist.
Dr. Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The author reports no relevant financial relationships.