Location, location, location

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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You identify a lesion suspicious for a basal cell carcinoma on the eyelid and do an incisional biopsy. You code CPT 67810, as this is a site-specific eyelid biopsy code. Is your code selection correct?

Both the CPT and the ICD-9 specify various procedural and diagnostic codes based upon procedure and lesion location. It is therefore crucial to proper coding to be clearly familiar with code and anatomical location definitions. The skin biopsy code, CPT 11100, can be used for any skin or mucosa location. The shave, destruction, and excision codes are uniformly separated into the same three repeated location areas:

1. Trunk, arms, or legs;

2. Scalp, neck, hands, feet, genitalia;

3. Face, ears, eyelids, nose, lips, mucous membranes

Repair codes (12001 — 13160) stratify locations slightly differently from the above, and the adjacent tissue transfer or rearrangement codes (14000 — 14350) are based upon smaller anatomical units.

For the purposes of precise coding based upon lesion location it is necessary to understand the anatomical demarcation zones on the head and neck. Everyone has an intuitive understanding of where the neck, scalp, and face are located. However, what are their defined demarcation lines? The separation between the face (forehead) and the scalp is at the hairline. However, one must take into account receding hairlines. The scalp does not recede along with a hairline. The scalp starts and the forehead ends above the line of demarcation of a youthful hairline. The face ends and the neck starts below the level of the mandible. The scalp ends and the neck starts inferior to the junction of the hard bony skull and the soft tissues below it. On the posterior aspect of one’s head and neck both the scalp and the neck bear coarse terminal hairs. The hairline is therefore useful for demarcating the face from the scalp but not the scalp from the neck. [pagebreak]

There are select location CPT codes for the lip, oral mucosa, and eyelids.

CPT code 40490, “biopsy of lip,” refers to biopsies done on the lip internal to the vermilion-skin margin (that is, on the lip vermilion or mucosa). Any biopsy done on the skin of the lip only merits an 11100 skin biopsy CPT code. Note that CPT 11100 is defined as “biopsy of skin, subcutaneous tissue and/or mucous membrane.” Consequently, one may use either code 40490 or 11100 for specifying a lip biopsy done on the vermilion or mucosa.

There is a specific CPT code for eyelid biopsy: 67810, “Incisional biopsy of eyelid skin including lid margin.” This code was revised in the 2013 CPT to limit its use to procedures where the full thickness of the eyelid margin is biopsied. The lid margin is the portion of the eyelid edge extending from the skin and lash line to the palpebral conjunctiva. A biopsy involving the eyelid skin only is coded with CPT 11100.

CPT 67840, “excision of lesion of eyelid (except chalazion) without closure or with simple direct closure,” refers to an excision of the lid margin tissue with or without primary closure. Dermatologists would typically treat malignant lid margin lesions with Mohs surgery. Consequently, dermatologic use of this code is rare. Code 67850, “Destruction of lesion of lid margin (up to 1 cm),” may be used when the destroyed lesion is on the lid margin, as defined above. Destruction of eyelid lesions located on the skin outside the lash line should be specified with the appropriate premalignant (CPT 17000 — 17004) or benign (CPT 17110 — 17111) destruction codes.

Example 1: You excise an eyelid nevus that overlaps the lid margin from the skin of the eyelid through the lash line and onto the eyelid conjunctiva. You repair the defect with a flap. As you both excised the lesion and then repaired it with a flap you bill CPT 67961 for the excision and CPT 14060, adjacent tissue rearrangement, eyelids, for the flap repair. [pagebreak]

Answer: Incorrect. The adjacent tissue rearrangement code 14060 definition includes both the excision and the repair of the lesion. Only CPT 14060 should be billed.

Example 2: You identify a lesion suspicious for a basal cell carcinoma on the eyelid rim and do an incisional saucerize type of biopsy. No suturing is done. You code CPT 67810, as this is a site-specific eyelid biopsy code.

Answer: Correct. The incisional biopsy of the lesion includes more than skin, involving the full thickness of the eyelid rim extending from the lash line into the conjunctiva. This fits the definition of CPT 67810. Note that the code specifies a full-thickness eyelid margin biopsy only. Suturing is not mentioned in the code descriptor and is not required for use of this code.

Example 3: You do a punch biopsy of a lip lesion suspicious for a squamous cell carcinoma located on the junction of the vermilion and the internal lip mucosa. Your biller codes the procedure as a biopsy, CPT 11100.

Answer: Correct. CPT 11100 is defined as “biopsy of skin, subcutaneous tissue, and/or mucous membrane”. Thus it may appropriately be used for a lip vermilion or mucosa biopsy, with or without suturing. However, in this case CPT 40490, “biopsy of lip,” is also fitting, as the biopsy is from the non-skin portion of the lip. The choice is yours. If the biopsy had been performed only on wet mucosal tissue, CPT 40808, biopsy of vestibule of mouth, would be appropriate. See the May 2013 issue of Dermatology World, www.aad.org/dw/cracking-the-code/2013/may, for more details.

Example 4: You do a saucerize incisional biopsy of a clinically atypical eyelid nevus. The biopsy extends from the skin across the eyelid rim lash line to the tarsal glands orifices. You code CPT 67810, eyelid biopsy.

Answer: Incorrect. The full thickness of the eyelid margin was not captured in the biopsy. The biopsy involved skin and a partial thickness of the eyelid, as the biopsy did not extend full thickness across the eyelid rim to the conjunctiva. The correct code would be 11100, biopsy of skin, subcutaneous tissue, and/or mucous membrane.