Current Procedural Terminology (CPT) is very specific in what is included and what is excluded in the codes that define the excision of benign and malignant skin lesions. A dermatology practice cannot ignore the ramifications of proper coding and billing when skin lesions are completely removed. Documentation needs to be complete and concise in order to apply procedure codes to the utmost level of specificity. Even with thorough documentation on the physicianʼs part, the people who assemble and submit healthcare claims need to be aware of all the nuances involved in the coding process.
A skin lesion excision is defined by CPT as a full-thickness removal of the lesion, including margins, through the dermis. Both the definitions of benign skin lesion excisions (codes 11400-11446) and of malignant skin lesion excisions (codes 11600-11646) state in their introductions: “Excision (including simple closure) of [benign/ malignant] lesions of the skin.” Both introductions also restate that simple closure is an integral component of the procedures that follow and that simple closure should not be billed separately.
The National Correct Coding Initiative (NCCI) contains mutually exclusive edits (MUEs) that detect codes that cannot reasonably be expected to be reported together. One such MUE is the reporting of 11400 and 11201. The closure of a the superficial wound caused by the excision of a skin lesion on the trunk, arms, or legs, is considered a part of the excision. The standard of care demands that a dermatologist who makes a therapeutic wound to remove a lesion should be expected to place a simple stitch or butterfly to close the wound. To do otherwise would be negligent.
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CPT and NCCI both agree that simple closure following a benign or malignant lesion excision is an integral component of the primary procedure. In its definitions, CPT does not take extenuating circumstances into account, only the nature of the procedure performed. If a dermatologist argues that a closure was particularly involved, that it took longer than expected, or that it needed to be suspended in mid-procedure and then repeated, CPT does not take these considerations into account. As the introduction of the CPT manual states, codes are assigned to reflect the service performed. Approximation of code definitions is not permitted. Upcoding to reflect a higher level of service than what is accurately and adequately defined by another code that reimburses less, is evidence of fraudulent or abusive coding methodology.
No outpatient dermatology practice can afford to be exposed to a RAC or other third-party audit. Even if the findings are in the practiceʼs favor, the amount of time and material spent on supplying documentation to auditors to substantiate submitted claims is a drain on resources that negatively affects practice management and patient care.
The excision of skin lesions, as defined by CPT, includes the simple closure of the wound created. While NCCI can be circumvented by modifying the code for simple closure, if the service was a simple closure of an excision, it should not be billed. The excision code includes the whole patient encounter from start to finish.