The Issue of Intent

M any physicians continue to struggle with the issues of whether to code a procedure as a biopsy versus a shave removal versus an excision. I receive many faxes regarding the issue of intent. “I have always been told that my intent determines whether I code an excision versus a biopsy,” is a frequent comment made. Others link the final diagnosis as a determining factor. Others still mix up the whole matter by incorrectly describing the procedure they perform with terms such as a “biopsy excision,” a “shave excision” or an “excision removal,” for example. None of these types of procedures exist in CPT. The final blow to the whole issue is that, in many cases, the operative report is totally inconsistent with the CPT code selected and billed to the insurance carrier. Here, we’ll do a cursory review of some of the more common concerns and, hopefully, help providers select, code and document the procedure that is performed to assure a quality record and avoid audit discrepancies. Q: In many courses taught over the years at various national, state and specialty dermatology meetings, the issue of intent is frequently discussed in relation to lesion removal. I probably can dig up 20 or more handouts that state that the physician’s intent should be the determining factor in deciding whether one selects a biopsy, a shave removal or an excision. Let me get specific. A patient comes in with a lesion that clinically concerns me. I want to get a histological evaluation of the tissue to rule out malignancy. My intent is usually to obtain a biopsy sample, and since I remove the lesion as conservatively as possible, I code these all as biopsies. I never use the shave removal codes (e.g., 11300 – 11313) because I heard no carrier pays for these. I only use the excision of benign lesion codes for cysts. I use the excision of malignant lesion codes only when I have a pathology report first. Sometimes, the pathologist does confirm a complete removal of the malignant lesion; but since my intent was not to excise but rather to biopsy, I just shrug those off as the cost of doing business. Is intent still the golden rule? A: Oh my goodness! Where to start? First let’s address your many historical handouts gathered over the years at dermatology meetings and conferences. Those handouts are only as good as the next meeting. Information, coding guidelines, federal statutes and CPT change from month to month; year to year. Think of the excision codes, such as 11400 –11446 and 11600 -11646. In 2003, the definition changed as to how the codes are selected. They are now selected based on the lesion size including conservative margins. This measurement is now referred to as the “excised diameter” versus the previous descriptor of “lesion size.” So, you need to stay current on the issues of the day and throw away those old handouts, replacing them with the current version of CPT and updates from Medicare and your local managed care plans. Let’s talk about intent. Although intent sounds like a good concept; it’s really not a determining factor when it comes to lesion “removal.” Let’s take a look at the salient factors. 1. How was the lesion “removed” from the skin? If only a sample portion of the lesion is obtained (leaving some of the lesion behind) in order to obtain a pathologist’s diagnosis, then the biopsy code would be appropriate. If the lesion is removed, but the removal is superficial and does not extend into the fat, then the shave removal codes (11300 -11313) would be correct. If the lesion is removed and the excision extends down to the fat, then the excision of benign (11400 -11446) or malignant (11600 -11646) lesion codes is the way to go. The physician must determine exactly how the tissue was removed from the patient’s skin and avoid factoring in the reason for obtaining the tissue. The intent is always basically the same — obtain tissue for histologic review to rule out malignancy or confirm complete margins. The process of obtaining the tissue is ruled by how much and how deep the surgeon goes. Why is intent not important? I’ll show you why with the following example. A patient is examined and presents with a lesion that’s clearly consistent with a basal cell carcinoma (BCC). You perform a fusiform excision down to the fat. You take generous margins around the periphery of the lesion and repair the defect with an intermediate closure. You hold the charges because you want to confirm the diagnosis of BCC. Your operative clearly documents your full-thickness excision as well as the intermediate repair (including medical necessity). Several days later, the pathology report comes back confirming the diagnosis of BCC, but indicating that the excision was incomplete, requiring further re-excision. Now, your documentation supports excision of the whole thing, right? Just because the pathology report confirmed incomplete margins doesn’t require you to change the code to a biopsy. The process of obtaining the tissue didn’t change. Likewise, if you did and documented a biopsy but the pathology report confirmed a malignant lesion with complete excision of the tumor, how can you justify charging an excision of a malignant lesion if that’s not what you did or documented? You need to bill for what you documented that you did. 2. What documentation is present in the operative note? You can’t bill for the excision of a benign lesion (11400 -11446) if your operative note states you did a biopsy. The excision codes require documentation of “full-thickness removal” (through the dermis into the fat). Documentation, such as biopsy excision or shave excision, is inconsistent with CPT descriptors and auditors would most likely down-code these, upon audit, to biopsy or shave removal codes (if they don’t deny these altogether). Shave removal documentation (11300 -11313) should include the term “shave removal” and not phrases such as shave biopsy, biopsy removal or shave excision. Again, these terms are conflicting with CPT and most likely would be down-coded or denied upon review. 3. Diagnosis should not affect the procedure you did. What procedure you do (biopsy versus shave removal versus excision) should not be affected by the diagnosis. Obviously, if an excision is performed, you must distinguish between a benign and a malignant CPT code. However, the fact that you did and documented a biopsy doesn’t change no matter what the diagnosis turns out to be. Likewise, as in the aforementioned example, you don’t change the billing of an excision just because you didn’t get the entire lesion out at the first try. 4. The shave removal dilemma (codes 11300 -11313). Finally, I must address your comment about shave removal codes. It’s really not true that most carriers don’t pay for these. Most carriers do but, like excision codes, most carriers, including Medicare, have medical necessity criteria for and when these codes can be used. Most of the policies are pretty much the same and require that the lesion that is to be removed have certain signs and symptoms present (such as bleeding and pain). Additionally, most of these carriers also list the covered diagnoses allowed when billing these services. Most physicians and their staffs haven’t billed these codes in years because at some point (years ago) many of the carriers didn’t pay for these. And like many wives’ tales, the rumor passes from one billing staff generation to the next. “Don’t bill for shave removals; nobody pays for these codes,” becomes the etched-in-stone policy. 5. The “biopsy codes pay much better than shave removal code” myth. Some providers think they get paid better with the biopsy codes (11100 and 11101). First, always bill based on what was done and documented. Avoid choosing codes that pay better versus accurately reflecting what service was actually provided. Comparing Charges Among Codes Let’s review average charges for the two sets of codes: biopsy versus shave removal using the national Medicare average reimbursement rates for participating providers: 11100: $79.15 11101: $28.75 11300: $57.87 11301: $75.41 11302: $90.35 11303: $108.27 11305: $58.24 11306: $80.64 11307: $92.96 11308: $109.76 11310: $70.93 11311: $87.73 11312: $101.18 11313: $132.54. Except for 4 of the 12 codes, the shave removal codes pay more than the biopsy codes. This is especially true for lesions at least 6 mm in diameter or greater involving the scalp, neck, hands, feet, genitalia, face, ears, eyelids, nose and lips. Some staffs argue about the fact that the second shave removal code being reduced by 50% while 11101 is exempt from reduction also causes payment incentives. Reduce any shave removal code by 50%, and you’ll find they pay more than the second biopsy code (11101). You do the math. Tips to Remember 1. Document what you actually did. 2. Avoid conflicting terms in your operative report that are inconsistent with CPT descriptors. 3. Choose the CPT code that accurately reflects the service performed and documented. 4. Don't change your coding based on the final pathology report except to differentiate between excision codes for malignant and benign lesions. 5. Don't select a code based on reimbursement. Follow rules 1 through 4 not money versus more money.