Deciphering Confusing Codes

S everal codes in the CPT book seem to challenge coders and providers alike. Such confusion often stems for nebulous terminology that is not properly defined or clarified. Below are several recent faxes received on my national Dermatology Fax Hotline which seems to hone in on some of the points of confusion. Q: We are one of the few dermatology practices left in our community that treats warts, so we consequently see lots of patients with all types of warts in all types of locations. We are aware that there are specific CPT codes for treating these types of lesions in the anus, penis and vulva. Where our confusion arises is in distinguishing what constitutes simple versus extensive treatment. Can you provide some guidance on how I select one code over the other? A: Your question is a fair one and I should be able to clarify the issue for you, but unfortunately I am as simple minded as you are. First let’s review the codes so that everyone understands what we are talking about. CPT Codes for Warts of the Anus 46900 Destruction of lesions(s), anus (e.g. condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple: chemical 46910 electrodessication 46916 cryosurgery 46917 laser surgery 46922 surgical excision CPT Codes for Warts of the Penis 54050 Destruction of lesions(s), penis (e.g. condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple: chemical 54055 electrodessication 54056 cryosurgery 54057 laser surgery 54060 surgical excision 54065 Destruction of lesions(s), penis (e.g. condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive: any method CPT Codes for Warts of the Vulva 56501 Destruction of lesion(s), vulva; simple, any methods 56515 extensive, any method CPT makes absolutely no reference as to what constitutes a simple treatment versus one that is extensive. This is one of those opportunities for the physician to make the determination and choose the code he/she feels is most appropriate. Time, effort, complexity of the therapy, number of lesions, size of the lesions (several isolated lesions versus one large contiguous cluster) and risk should all be taken into consideration in making the final selection. And of course, if you go with the extensive codes, be sure you document as completely as possible so that your choice of codes is clearly supported by your documentation. Q: I am relatively new in practice and I’m struggling with my coding. As with most dermatologists who just completed their residency program, we didn’t really learn the nuances of coding. I am reading as much as I can and carefully reviewing the CPT book. In spite of my efforts, I find many discrepancies and seem to be as clueless as ever. Because I am new to the area, I attract a lot of acne patients. One of my questions is about treating milia. I find two codes that both include milia in their definition (e.g., CPT codes 10040 and 17110). Which one do I pick? What is the difference? A: First, kudos to you for the effort you’re making on educating yourself on coding. Forgive me for this plug, but you might consider the Dermatology Coding Correspondence Course offered by the Inga Ellzey Practice Group (that’s me!). We have had this course for over nine years and have had over 400 physician graduates. You can take the course on-line and get 30 CEU credits to boot. It’s the ultimate learning tool for mastering dermatology coding. With respect to your questions, the difference between CPT code 10040 (Acne surgery - e.g., marsupialization, opening or removal of multiple milia, comedones, cysts and pustules) and CPT code 17110 (destruction - e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement — of flat warts, molluscum contagiosum, or milia) is that the 17110 code is a destruction while the 10040 code is a removal. Hint: any code that starts with “17” is a destruction code. As per the definition, the most common forms of destruction include the application of liquid nitrogen or other chemical agent, curettage, electrodessication, or the use of a laser. The removal of milia is usually accomplished with a comedone extractor. Using Medicare rates as a measuring stick, reimbursement using one over the other is negligible. CPT code 10040 comes in at $85.27 while 17110 pays $87.92. Good luck with your practice. Q: When I incise and drain an infected cyst, I usually use CPT code 10060 (incision and drainage of abscess — e.g., carbuncle, suppurativa hidrandenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia — simple or single). I never use CPT code 10061 (which states “complicated or multiple”). When actually do I use CPT code 10061 and what makes a cyst I&D complicated? A: Here again is an example where CPT started the race, but never finished. Clearly, it’s not difficult to make the distinction between single and multiple. Differentiating between simple and complicated, however, is another matter. I have found nothing formally published by the American Medical Association that provides any insight into the distinction between the two. I have always advised physicians and coders to consider several criteria; the most important being the insertion of a drain or gauze that would require a follow-up visit within the ten day post-op period. Obviously, the insertion of a drain or gauze would indicate that the treatment of the lesion is not simple, but requires more effort, skill, and supplies. Additionally, the need for another visit within the global period is also required for drain removal and wound care assessment. Other criteria could include infection, the size of the lesion, the need for culturing and, complexity of the dressing. The combination of any of these may substantiate the use of the more complicated code although there is nothing formally written on this subject. It’s anyone’s guess what some auditor from some managed care plan or Medicare thinks is the appropriate use of CPT code 10061. At least you’ll have some ammunition if your documentation describes a more complex procedure. Although the postoperative time frames are the same (ten days for both codes 10060 and 10061), payment is significantly more for code 10061 (which I feel confident reflects the extra work and added office visit). Using Medicare’s 2005 allowables for Participating Physicians, you can see the difference in payment for CPT code 10060 at $94.74 versus 10061 at $169.78. A final comment, whether you choose CPT codes 10060 or 10061, you cannot bill any visits during the postoperative period that are related to the treated lesion(s).