||This is the third article in a six-part series that focuses on areas where dermatology is vulnerable, and how members can take action to preserve the ability to practice the full scope of dermatology for the benefit of patients. Watch for the Adapt, Commit, Thrive (ACT) logo in the next three issues of Member to Member to keep abreast of the critical issues facing the specialty in light of health system reform implementation.
By David E. Geist, MD
Dermatologists use different methods and techniques to treat, remove, or destroy symptomatic and/or concerning skin lesions. Appropriate code selection depends on the lesion morphology, symptoms, and technique used, e.g., removal by shave, destruction, or excision technique. According to the Medicare Local Coverage Determination (LCD), there may be instances in which the removal or destruction of these lesions may be medically appropriate.
There has been a large increase in destruction code utilization, prompting increased claim scrutiny by payers in general. In light of this trend, the AAD encourages all dermatologists and their staff to ensure that services rendered are driven by medical necessity, and that adherence to medical coverage policies is observed.
Services that are not deemed medically necessary must always be the responsibility of the patient and never billed to the health plan.
According to the Medicare Local Coverage Determination (LCD), "lesion removal is considered medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record:
- Intense itching;
- Sudden, rapid enlargement (during one month of observation);
- There is physical evidence of inflammation (e.g., purulence, oozing, edema, erythema, erosion, etc.);
- The lesion(s) obstructs an orifice or clinically restricts vision;
- There is clinical uncertainty about the likely diagnosis, particularly where malignancy is a realistic consideration. This is based on lesion appearance or prior biopsy of a related or if a similar lesion suggests or is indicative of malignancy."
Note: This list is not exhaustive, so please review your Medicare LCD in its entirety to understand the guidelines and regulations pertaining to coverage.
Removal by destruction technique
Destruction is defined as, "The ablation of benign, premalignant, or malignant tissues by any method (electrosurgery, cryosurgery, laser, and chemical treatment), with or without curettement, including local anesthesia and not usually requiring closure."
These services are appropriately reported using CPT codes 1700x destruction, pre-malignant lesions; 1710x, cutaneous vascular proliferative lesion; 1711x, benign lesions; and 1726x, malignant lesions.
The following examples illustrate destruction of dermal and epidermal lesions, and their corresponding proper coding.
Example 1: A 48-year-old construction worker presents with two scaly 5x4 mm erythematous papules of six months' duration on the arm. Upon inspection and examination, the lesions are compatible with the diagnosis of actinic keratoses. The provider reviews pertinent data in the patient's chart, as well as the current medication list and allergies. Risks and benefits of various treatment options are discussed and a decision is made to destroy the lesions using liquid nitrogen applied directly to the skin. An informed consent is obtained and the patient is prepped for the procedure. The patient is advised about wound care and is to return to the office in seven days for follow-up.
This service is appropriately reported as 17000: destruction (e.g., laser surgery, electrosurgery, cryosurgery), premalignant lesions (e.g. actinic keratosis); first lesion and 17003 x 1 for the subsequent lesion.
Example 2: A 50-year-old boater has a discreet but irregular 8mm shiny, red, flat lesion on his back. The clinical diagnosis is probable superficial basal cell carcinoma, and the dermatologist elects to shave the lesion at the level of the mid dermis.
There are multiple ways this service may be reported:
- If the intent of this procedure is therapeutic, it is appropriately reported as a shave removal, code 11301: shaving of epidermal or dermal lesion, single lesion, trunk, arms, legs; lesion diameter 0.6 cm to 1.0 cm.
- If the intent of this procedure is diagnostic, it would be coded as a skin biopsy, code 11100: biopsy of skin, subcutaneous tissue and/or mucus membrane (including simple closure), unless otherwise listed; single lesion.
In all cases, only the definitive procedure is reported. Because obtaining tissue for histopathology examination is a component of the definitive procedure, a skin biopsy is not separately reported for the same lesion.
Example 3: A woman presents with a lesion that is intermittently inflamed located under her left breast. The lesion appears to be benign, but it is irritated when she wears a bra and crusts over with some bleeding from friction with her bra. She would like to have the lesion removed. The lesion appears to be a seborrheic keratosis.
This case is appropriately reported with CPT code 17110: destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions.
Example 4: An 8-month-old baby presents with a rapidly growing 2.0 cm bright red plaque on the right cheek that is diagnosed as a port wine stain. The provider discusses the diagnosis with the parents, as well as a therapeutic laser procedure that is to take place, and describes the risks, benefits, and alternatives. An informed consent is obtained from the parents. Special attention is placed on the emotional issues related to the procedure. The family is advised of the post-operative appearance of the laser-induced wound and the care.
This procedure is appropriately reported as 17106: destruction of cutaneous vascular proliferative lesion (e.g., laser technique); less than 10 sq cm. Codes 17106-17108 are specific to destruction of benign cutaneous vascular proliferative lesions (e.g., port wine stains), and are reported based on square centimeters. Only one code would be reported for the total square centimeters of the area treated.
Example 5: A 0.6 cm flat, red to black lesion on the arm of a 32-year-old tanning bed user is diagnosed as a probable pigmented basal cell carcinoma, with melanoma a less likely consideration. The lesion is shaved off with a blade, including a 0.2 cm margin. The wound base is then electrodessicated and curetted, leaving a 1.0 cm wound. Pathology confirms a pigmented basal cell carcinoma, and the deep and lateral margins are uninvolved.
This procedure is appropriately reported as 17261: destruction malignant lesion arm, 0.6-1.0 cm diameter. It is not reported as an excision, because the level of removal did not extend through the dermis, nor would it be reported as a shave removal because the lesion was destroyed after the specimen was obtained for pathology.
Note: These are just a few examples; for the most definitive procedure code selection, it is recommended to hold for the pathology report. If the pathology report reveals malignant diagnosis, report a malignant destruction code from 172xx series. If the pathology report confirms that the lesion is benign, a shave (113xx) or biopsy (11100) code is reported — depending on the procedure performed — because the destruction would generally not meet the test of medical necessity. In instances in which the lesion was symptomatic (e.g., inflamed seborrheic keratosis) and local policies allow it, a benign destruction (17110) may be reported instead.
If you need more information about reporting lesion removal,
review previous issues of Derm Coding Consult
and the AAD's 2014 Coding and Documentation for Dermatology manual
Dr. Geist is chair of the American Academy of Dermatology’s Coding and Reimbursement Task Force. He is a Mohs Surgeon at Adult and Pediatric Dermatology, PC, in Marlborough, Mass., and Concord, Mass.
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