Coding for procedures in Skin Disease and CareGlobal Period- A global period for a procedure is the duration of time included for non-billable routine surgical follow-up after the affiliated procedure
- Routine care such as suture removal, dressing changes, and follow-up during the postoperative period cannot be billed if it falls within the global period
- If the visit is unrelated to the procedure or if there is an unexpected complication from the surgery (i.e., hematoma), then you will get reimbursed as long as you code it properly
| | | | | | | Procedures with NO GLOBAL PERIOD | | | • Biopsies: | | • Others: | | | ⇒ Skin biopsy (11100) | | ⇒ IL injections (11900–11901) | | | ⇒ Skin biopsy add-on (11101) | | ⇒ Shave removals (11300–11313) | | | ⇒ Eyelid biopsy (67810) | | ⇒ Paring/cutting benign hyperkeratotic lesions (11055–11057) | | | ⇒ External ear biopsy (69100) | | •Mohs micrographic surgery: | | | ⇒ Lip biopsy (40490) | | ⇒ Head, neck, hands, feet, genitalia (17311, 17312) | | | ⇒ Vulvar biopsy (56605) | | ⇒ Trunk, arms, legs (17313, 17314, 17315) | | | ⇒ Penile biopsy (54100) | | | | | ⇒ Nail biopsy (11755) | | | | Excision Codes – 10 DAY GLOBAL PERIOD | | | • Benign Excision | | • Malignant Excision | | | ⇒ Trunk, arms, legs (11400–11406) | | ⇒ Trunk, arms, legs (11600–11606) | | | ⇒ Scalp, neck, hands, feet, genitalia (11420–11426) | | ⇒ Scalp, neck, hands (11620–11626) | | | ⇒ Face, eyelids, ears, nose, lips (11440–11446) | | ⇒ Face, eyelids, ears, nose, lips (11640–11646) | | Destruction Codes – 10 DAY GLOBAL PERIOD | | | • Premalignant | | • Destruction of lesion in genital area | | | ⇒ First lesion (17000) | | ⇒ Anal, simple chemical (46900) | | | ⇒ Additional lesions, up to 14 (17003) | | ⇒ Anal, electrodessication (46910) | | | ⇒ ≥ 15 lesions (17004) | | ⇒ Anal, cryosurgery (46916) | | | • Benign | | ⇒ Anal, laser surgery (46917) | | | ⇒ 1 – 14 lesions (17110), ≥ 15 lesions (17111) | | ⇒ Anal, surgical excision (46922) | | | • Malignant | | ⇒ Penile, simple chemical (54050) | | | ⇒ Trunk, arms, legs (17260–17266) | | ⇒ Penile, electrodessication (54055) | | | ⇒ Scalp, neck, hands, feet, genitalia
(17270–17276) | | ⇒ Penile, cryosurgery (54056) | | | ⇒ Face, eyelids, ears, nose, lips (17280–17286) | | ⇒ Vulva, any method (56501) | | | | ⇒ Vulva, extensive (56515) | | Repairs – 10 DAY GLOBAL PERIOD | | | • Simple Repair | | • Intermediate Repair | | • Complex Repair | | | ⇒ Scalp, neck, trunk, extremities, hands, feet (12001–12007) | | ⇒ Scalp, trunk, extremities
(12031–12034) | | ⇒ Trunk (13100–13102) | | | ⇒ Face, ears, lips, mucous membranes
(12013–12018) | | ⇒ Neck, hands, feet
(12041–12044) | | ⇒ Scalp, arms, legs
(13120–13122) | | | | ⇒ Face, ears, eyelids, nose, lips (12051–12053) | | ⇒ Face, neck, hands, feet
(13131–13133) | | | | | ⇒ Eyelids, nose, ears, lips
(13150–13153) | | Flaps and Grafts – 90 DAY GLOBAL PERIOD | | | • Adjacent Tissue Transfer/Rearrangement | | • Others | | | ⇒ Trunk (14000–14001) | | ⇒ Skin substitute or replacement such as graft (15000–15431) | | | ⇒ Scalp, arms, legs (14020–14021) | | | | ⇒ Forehead, cheeks, chin, mouth, H/F
(14040–14041) | | | | ⇒ Eyelids, nose, ears, lips (14060–14061) | | | | ⇒ ≥30 cm2 area – unusual or complicated (14300) | |
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Modifiers (Table 10-4)- A modifier is a two digit code appended to a CPT code to indicate a special circumstance when reporting a service
- Many procedure codes are bundled together and if those bundled code combinations are billed together, generally Medicare will only reimburse one of the codes, typically the one with the lower value
- Many insurance companies follow the bundling edits of Medicare, so it is important to know which codes are bundled together
- The use of modifiers helps to communicate with computer programs to override these bundling edits in the software programs
- Modifiers are also critical during the global period in ensuring that providers receive reimbursement for services unrelated to the primary procedures, in addition to staged procedures, multiple procedures, and evaluation and management (E&M) services
- Correct Coding Initiative (CCI) is Medicare’s national editing software system that bundles various procedural code combinations
- A CCI edit is a pair of CPT codes that are not separately payable except under certain circumstances, and it requires careful monitoring because these edits are updated quarterly by Centers for Medicare and Medicaid (CMS)
- CCI edits apply to all physicians who bill for services on the Medicare claims processing form, and the edits may be obtained via the CCI Edits Manual by going to the CMS website (https://www.cms.hhs.gov/NationalCorrectCodInitEd/), where a listing of the CCI edits by specific CPT sections is available for free downloading
- CCI versions are updated quarterly (January, April, July, and October)
- When looking at the CCI table, there will be either a 0 or 1 next to the CPT code, which is the indicator code for the associated CPT code relaying if a particular modifier will indeed override the computer edit and result in reimbursement; zero indicates no circumstances in which modifier appropriate, and the number one indicates modifier is allowed to distinguish between services provided (i.e., modifier 59 will override the computer “edit” and thus result in reimbursement)
- The examples below are to show there is no rhyme or reason as to which codes are bundled
- CCI edits must be used that were in effect that quarter so the edits below will likely have already changed
| | | | | | | | Not bundled | | Bundled | | | - Skin biopsy (11100) + site-specific skin biopsy (lip, external ear, genitalia, etc.)
- Destruction of AKs + destruction of malignant lesion
| | - Destruction of AKs (17000) + skin biopsy (1110)
- Destruction of AKs (17000) + excision of malignant lesion
- Excision of malignant lesion + adjacent tissue transfer
| | | | | | | | | Adjacent tissue transfer code has excision already included, so cannot bill separately for excision | | | | | | | | |
| | - MOHS procedure + pathology (path is integral part of MOHS reimbursement, so cannot be billed separately)
- Office visit + procedure
- Two procedures on same visit (i.e., biopsy and excision)
- Two procedures with exact same CPT code
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| | | | | | | Table 10-4 Common Modifiers | | | Modifier | | Description | | Comments | | | 24 | | Unrelated E/M service by same physician during postoperative period of procedure | | Shows E/M unrelated to the surgery; modifier only attached to E/M visits (99XXX), not procedure codes | | | 25 | | Significant and separately identifiable E/M service by same physician on same day of procedure or other service | | - Attach this modifier only to codes related to E/M visits (99xxx), not procedure codes
- Must have substantial documentation that satisfies criteria for respective E/M level
| | | 58 | | Re-excision during postoperative period by same physician | | - Use for planned staged excision, re-excision of incompletely excised lesion, or wider excision to obtain further margins after initial excision (i.e., wider excision for melanoma)
| | | 59 | | Distinct and independent procedure performed on the same day as another procedure | | - Used to report services that are not normally reported together but are appropriate under the circumstance (used to unbundle same day surgical services); attach modifier to procedure code
| | | 79 | | Unrelated procedure or service by same physician during the postoperative global period of a procedure | | - Indicates the performance of a procedure during a postoperative period which was unrelated to the postoperative care of the original procedure
- Always put this modifier first (i.e., 17110–79, 59)
| | | 91 | | Repeat clinical diagnostic lab test | | - If two KOHs or scabies preps performed at two different sites, use this modifier
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Important Points| | | | | | Following applies to Medicare and many other insurance carriers | | | | | |
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- The postoperative day does not start until the day after the procedure
- Use modifier 79 for complications during the postoperative period (i.e., hematoma)
- If performing an excision on one day and the repair is on another day, both can be reimbursed with modifier 58 (need medically necessary reason for delaying the repair)
- Cannot bill a biopsy code with another surgical service for the same EXACT lesion on the same day (i.e., for clinical BCC, cannot bill for biopsy and C&D)
- If you are covering for another physician in your group, cannot bill for a suture removal or dressing change visit if related to the original procedure and still within the global period
- Multiple reduction rule in surgery: first procedure paid at 100%, but second and any additional is paid at 50%
- When lesion excised and requires only simple closure, cannot bill for simple repair (12001–12018) since this is considered part of the reimbursement for the excision
- When medical records are requested by an insurance company, be sure to review every document before sending it; if you need to make any addendums, use the current date and time (do not back date)
Coding Examples- Removal of a 0.7 × 0.7 cm atypical nevus (on arm) with 2 mm margins on either side via mid-dermal shave technique → 11301 (shave removal for 0.6–1.0 cm lesion) or 11100 (biopsy code if unsure whether removed completely); unable to bill for excision (11401) since it is not a full thickness removal through the dermis; unable to bill 11302 (1.1–2.0 cm) since uninvolved margins are not added to diameter of a shave removal
- Removal of 0.5 × 0.5 cm atypical nevus (arm) with 6 mm circular blade (punch excision) with one superficial suture → 11401 (excision 0.6–1.0 cm); able to bill for excision since it is a full thickness removal; lateral margins are added to determine excised diameter in excisions (unlike shave removals)
- Atypical nevus removed and pathology report consistent with moderate to severe cytologic atypia with recommendation for wider clinical excision → ICD9 code 238.2; would not be coded as a malignant diagnosis or malignant excision code
- Removal of a 0.7 × 0.4 cm atypical nevus (chest) performed with 2 mm margins on either side in elliptical excision → 11402 (excision, trunk 1.1–2.0 cm); use lesion’s widest diameter (0.7 cm) plus margins (0.2 + 0.2) to determine proper excised diameter (1.1 cm)
- Malignant growth excised but unable to do primary closure so transposition flap constructed and used to close site → 14000 only; unable to bill excision (benign or malignant) code as flap code includes the excision and should not be reported separately
- Patient was seen last week for treatment of actinic keratoses and now comes back 8 days later for a new problem (i.e., new growth) and you perform a biopsy → 99213 (modifier 24, 25), 11100 (modifier 79); must use postop modifiers as you are still in 10 day global period
- Patient was seen last week for a growth on the hand and you performed a biopsy and now 8 days later patient comes in for new problem (actinic keratoses) which you treat with liquid nitrogen → 99213 (modifier 25), 17000, 17003 (no modifier); no postop modifiers needed in this case as a biopsy has no global period
- Patient seen 11 days after cryodestruction of actinic keratoses for a site which was treated (i.e., painful or infected) → 99213 (no modifier); no modifier needed since after 10 day global period of premalignant cryodestruction
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