Destruction codes for pre-malignant and malignant lesions

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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How do I code for destruction of premalignant lesions?

Codes 17000-17004 are specific to the reporting of destruction of premalignant lesions, such as actinic keratoses, and are reported based on the number of lesions treated, rather than the lesion size.

Code 17000 is reported for destruction of the first lesion, and code 17003 is reported for the destruction of each lesion from the second through the fourteenth. Code 17003 must be reported with its parent code 17000. 17003 does not require modifier 51 to be appended as this is an add-on code, and the reduction has already calculated into the value of this code.

Code 17004 is reported as a stand-alone code for destruction of 15 or more premalignant lesions. It should never be reported in conjunction with 17000 or 17003. Because the value of the code is based largely on add-on codes, and the multiple surgery reduction is already calculated into the value of these codes, 17004 is exempt from the 51 modifier.

How do I code for destruction of malignant lesions?

The destruction of malignant lesions is reported using codes 17260-17286. These codes are specific to the anatomic location of the lesion as well as the lesion diameter.[pagebreak]

Examples:

You destroy 17 actinic keratoses. How should this be coded?

This would be coded with 17004 (destruction of 15 or more actinic keratoses). No additional codes or modifiers are necessary.

You destroy eight actinic keratoses on the face and a 2.2 cm lesion of Bowen’s disease on the left arm.

You should code 17000 for the first actinic keratosis, 17003 X 7 units for the second through eighth actinic keratosis and 17263 59 for the lesion of Bowen’s disease. The 17000 code would be subject to the multiple surgery reduction rule. 17003 is an add-on code and is not subject to the multiple surgery reduction rule. Medicare automatically appends the 51 modifier where appropriate (you do not need to append it on your claim form for Medicare but a few private payers require it).

Your patient presented with a 4 cm mottled pigmented patch on the cheek. You suspected lentigo maligna, but a 4 mm punch biopsy showed pigmented actinic keratosis. How should you code the subsequent destruction?

Be careful. Don’t trust the biopsy result. Lentigo maligna occurs in collision with secondary lesions such as pigmented actinic keratosis 48 percent of the time, and a small biopsy can easily result in a sampling error. A broad, paper-thin shave biopsy, or better yet, multiple small shave biopsies representative of each color or morphology within the mottled lesion, would be preferable to a single punch biopsy. (This is one instance where it may be reasonable to submit all of the specimens in a single bottle, as you are essentially asking “is there lentigo maligna in there anywhere?” Ask your dermatopathologist if this will work for him or her.) If these biopsies ultimately confirm the diagnosis of actinic keratosis and the lesion is destroyed by cryotherapy, 17000 would appropriately be reported along with modifier 22, indicating Increased Procedural Services. Modifier 22 would be added in this case because the lesion in question is quite large (4 cm). The justification for the use of the modifier should be clearly indicated in the medical record.