Calculating your Lesion and Wound Coding
How are you doing with your Lesion and Wound Care Coding? Many Physicians across specialties perform skin procedures so its important that we understand the proper coding and documentation required.
I will be discussing this at Healthcon 2022 in Washington D.C. so I hope you can attend with me.
Knowing the guidelines for Lesion Excision and Wound Repair is crucial because at times they are bundled and the calculation methods are very different. Let’s start with Lesion excision.
Lesion Excision: Do the Math
Yes Lesion excision may require math. You need the Margins and the largest diameter excised documented by your Physician. This needs to happen prior to sending it off to pathology.
Why? Well what happens when a sample goes to pathology it may shrink. It’s definitely better to have some measurements so if you have to use path, and that’s all you have, well you need a measurement but it will be more accurate if documented prior to excision measurements taken prior to excision.
What do you need before you start?
- Is it Benign or Malignant? This changes the code set as for Benign you are looking at 11400-11446 and if Malignant 11600-11646
- Location , Location, Location. The sites are all describes in each main code 11400,11420,11440 and so you need to know where the site belongs code-wise.
- Size is Crucial! Your code will change based on cm and so you need to do the calculation. You have to add margins on both sides with the largest diameter of the lesion so if its 3×2 the 3cm is the largest. Then you take your physicians documentation of margins, which typically is 1.5 on each side but can be smaller like .5cm. So for instance: You have 1.5 on each side and that totals 3cm. You will add 3cm +1.5+1.5=6cm
- Code each Lesion Separate. Yes you code them all individually.
What do we do when our measurements are in mm and cm?
Like I said lets do the math. I will show you an example
Patient presents to the physician for removal of a squamous cell carcinoma of the right cheek. After the area is prepped and draped in a sterile fashion the surgeon measured the lesion and documented the size of the lesion as 2.3 cm at its largest diameter. Additionally, the physician took margins of 2 mm on each side of the lesion. Single layer closure was performed. The patient tolerated the procedure well.
I have highlighted our key points. Here is the math:
2.3cm +(2mm +2mm=.4cm)=2.7cm
The question remains what if I do not get the margins? Well that is a lot of times the case with many reports. If you do not have margins we follow our rule of coding: “Code what you have in front of you” You code the largest diameter which is the only measurement you have. I hope that helps clear up confusion.
Close the Gap in Wound repair Coding
Next we come to the repair or closure. There are times when a lesion excision or an open wound needs closed after a procedure and we need to know when that it billable.
Per the guidelines: ” The excision of benign lesions includes simple repair. If the wound requires (layered) closure, intermediate, see 12051–12057; complex, see 13151–13153.” CPT®
There are steps just like in lesion excision for the coding but make sure you pay attention to the layers. When it says “layered closure” it means the layers of skin so if its more than the simple layers of skin and goes deeper into Subcutaneous and Facia you have layers and that constitutes Intermediate.
So we know simple closure is not billable with other procedures but you can bill it if that’s all you are doing at that site.
- Complexity: Is it Simple, Intermediate or Complex?
- Location: What site is repaired. Just like lesion excision the codes are grouped into location areas.
- Size: Codes are based on cm and have a range of measurements.
How do you calculate? Well we have to take the wounds of the same complexity and location grouping and add them up to fit them into the correct code calculation. This is different that lesion excision where we code each separate. You can have multiple closure codes with different complexities. Let’s look at an example:
Patient presents to the emergency department with multiple lacerations from a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest
We have a simple closure, of 7.6cm for the right forearm which is reported with 12004. We also have a new complexity of intermediate closure on the arm of 5.7 cm and the upper chest 10.3 cm. The (chest) and extremities (arm) are in the same anatomic code set and are both the same complexity of intermediate, so we add them up for a total of 16 cm and use code 12035. Finally we have a complex repair of the neck, 4.7 cm which is 13132.
It can be complex but when you break it down and keep things organized you can do it!
Come see me at Healthcon and learn more about documentation and other common FAQ about wound care and Skin procedures
AAPC PMCC ®