This year, we are faced with new coding challenges. Decreasing fee schedules by Medicare have become our Christmas and Hanukkah presents year after year. However, many of us are still miscoding some procedures, and we could increase our revenue by learning to avoid these mistakes — a move that would help offset the losses we face from those “holiday gifts” we get from Medicare.
One of the coding pitfalls I see over and over again is quite surprising. Every time I lecture on the subject of site-specific biopsy coding, I am always amazed at how many dermatologists are still unclear about how to do this.
Don’t Fall into This Trap
Skin biopsy is probably the most common procedure that dermatologists perform every day. Most of us use CPT code 11100 for the first biopsy and then 11101 for the second biopsy and subsequent others. These two codes are not site-specific skin biopsy codes, and therefore they represent the least relative value units (RVUs) with least allowable on the fee schedules.
It is important to remember that 11101 does not require modifier 59 since it is an add-on code and cannot be used without 11100. Therefore, RVU is already inherently reduced for 11101. It is crucial to fight some of the managed care organizations that reimburse 50% of the already inherently reduced value of 11101.
Under any circumstances, 11101 should be paid at its 100% value and should not be subject to multiple surgery reduction rules.
On the other hand, site-specific skin biopsy codes are subject to multiple surgery reduction rules. However, they all have higher RVUs than 11100 and 11101.
The tables in this column review all of the site-specific skin biopsy codes.
Taking a Closer Look at Site-Specific Biopsy Codes
Let’s take a look at a couple of examples of site-specific biopsy codes in order to get a better understanding.
Example I: A patient with a generalized eruption presents. You do a biopsy on the left arm and the right arm for definitive diagnosis. The same patient also has a suspicious lesion on the left superior helix. During this same visit, you also biopsy the lesion on the ear to rule out basal cell carcinoma. In this case, you should be reimbursed at the full allowable for 69100 and 11101 and at 50% allowable for 11100.
Example II: Patient presents with a suspicious lesion on the right lower eyelid, the left lower lip and the tip of the nose. You go ahead and biopsy all of these areas. In this case, you should get reimbursed at 100% for 67810 and at 50% RVU for 40490 and 11100 since both of these codes are within the multiple surgery reduction criteria.
Example III: A patient presents with whitish suspicious areas on both sides of her labia majora and similar lesions on the anterior tongue. You go ahead and biopsy all three areas. In this case, 56606 is an add-on code to 56605, just like 11101, and cannot be used alone. Therefore, it is not subject to the multiple surgery reduction rules and should be reimbursed at 100% of its allowable. However, 56605 and 41100 are subject to the multiple surgery reduction rules; 41100 will be reimbursed at 100% of its allowable since it has a higher RVU, and 56605 at 50%.
Codes to Use When Waiting for Biopsy Results
As you noticed, in all of the above examples, I used either ICD code 238.2 (Neoplasm of skin, unknown origin) or 782.1 (Non-specific skin eruption) for diagnosis codes. These ICD codes are available for you to use so that you do not have to wait for biopsy results before billing your charges. Not only will this facilitate your payment, but it will also make life much easier for your office staff by eliminating paperwork.
There is absolutely no reason for you to know the diagnosis to code for a biopsy. Regardless of the diagnosis (malignant or benign), reimbursement is the same. Only excision codes are reimbursed at a higher level for malignant lesions.
Actually, if you use the biopsy results as your ICD code for biopsies, you may face this question in a future audit, “Why did you biopsy this lesion, doctor, if you already knew that it was a basal cell carcinoma?” Therefore, it is highly recommended to use these two ICD codes (238.2 or 782.1) for your biopsies.
Avoiding Revenue Losses
As you can see from the examples discussed in this column, it is important to be aware of the site-specific biopsy codes and use them appropriately for both correct coding purposes, as well as to avoid loss of significant revenue.
This year, we are faced with new coding challenges. Decreasing fee schedules by Medicare have become our Christmas and Hanukkah presents year after year. However, many of us are still miscoding some procedures, and we could increase our revenue by learning to avoid these mistakes — a move that would help offset the losses we face from those “holiday gifts” we get from Medicare.
One of the coding pitfalls I see over and over again is quite surprising. Every time I lecture on the subject of site-specific biopsy coding, I am always amazed at how many dermatologists are still unclear about how to do this.
Don’t Fall into This Trap
Skin biopsy is probably the most common procedure that dermatologists perform every day. Most of us use CPT code 11100 for the first biopsy and then 11101 for the second biopsy and subsequent others. These two codes are not site-specific skin biopsy codes, and therefore they represent the least relative value units (RVUs) with least allowable on the fee schedules.
It is important to remember that 11101 does not require modifier 59 since it is an add-on code and cannot be used without 11100. Therefore, RVU is already inherently reduced for 11101. It is crucial to fight some of the managed care organizations that reimburse 50% of the already inherently reduced value of 11101.
Under any circumstances, 11101 should be paid at its 100% value and should not be subject to multiple surgery reduction rules.
On the other hand, site-specific skin biopsy codes are subject to multiple surgery reduction rules. However, they all have higher RVUs than 11100 and 11101.
The tables in this column review all of the site-specific skin biopsy codes.
Taking a Closer Look at Site-Specific Biopsy Codes
Let’s take a look at a couple of examples of site-specific biopsy codes in order to get a better understanding.
Example I: A patient with a generalized eruption presents. You do a biopsy on the left arm and the right arm for definitive diagnosis. The same patient also has a suspicious lesion on the left superior helix. During this same visit, you also biopsy the lesion on the ear to rule out basal cell carcinoma. In this case, you should be reimbursed at the full allowable for 69100 and 11101 and at 50% allowable for 11100.
Example II: Patient presents with a suspicious lesion on the right lower eyelid, the left lower lip and the tip of the nose. You go ahead and biopsy all of these areas. In this case, you should get reimbursed at 100% for 67810 and at 50% RVU for 40490 and 11100 since both of these codes are within the multiple surgery reduction criteria.
Example III: A patient presents with whitish suspicious areas on both sides of her labia majora and similar lesions on the anterior tongue. You go ahead and biopsy all three areas. In this case, 56606 is an add-on code to 56605, just like 11101, and cannot be used alone. Therefore, it is not subject to the multiple surgery reduction rules and should be reimbursed at 100% of its allowable. However, 56605 and 41100 are subject to the multiple surgery reduction rules; 41100 will be reimbursed at 100% of its allowable since it has a higher RVU, and 56605 at 50%.
Codes to Use When Waiting for Biopsy Results
As you noticed, in all of the above examples, I used either ICD code 238.2 (Neoplasm of skin, unknown origin) or 782.1 (Non-specific skin eruption) for diagnosis codes. These ICD codes are available for you to use so that you do not have to wait for biopsy results before billing your charges. Not only will this facilitate your payment, but it will also make life much easier for your office staff by eliminating paperwork.
There is absolutely no reason for you to know the diagnosis to code for a biopsy. Regardless of the diagnosis (malignant or benign), reimbursement is the same. Only excision codes are reimbursed at a higher level for malignant lesions.
Actually, if you use the biopsy results as your ICD code for biopsies, you may face this question in a future audit, “Why did you biopsy this lesion, doctor, if you already knew that it was a basal cell carcinoma?” Therefore, it is highly recommended to use these two ICD codes (238.2 or 782.1) for your biopsies.
Avoiding Revenue Losses
As you can see from the examples discussed in this column, it is important to be aware of the site-specific biopsy codes and use them appropriately for both correct coding purposes, as well as to avoid loss of significant revenue.
This year, we are faced with new coding challenges. Decreasing fee schedules by Medicare have become our Christmas and Hanukkah presents year after year. However, many of us are still miscoding some procedures, and we could increase our revenue by learning to avoid these mistakes — a move that would help offset the losses we face from those “holiday gifts” we get from Medicare.
One of the coding pitfalls I see over and over again is quite surprising. Every time I lecture on the subject of site-specific biopsy coding, I am always amazed at how many dermatologists are still unclear about how to do this.
Don’t Fall into This Trap
Skin biopsy is probably the most common procedure that dermatologists perform every day. Most of us use CPT code 11100 for the first biopsy and then 11101 for the second biopsy and subsequent others. These two codes are not site-specific skin biopsy codes, and therefore they represent the least relative value units (RVUs) with least allowable on the fee schedules.
It is important to remember that 11101 does not require modifier 59 since it is an add-on code and cannot be used without 11100. Therefore, RVU is already inherently reduced for 11101. It is crucial to fight some of the managed care organizations that reimburse 50% of the already inherently reduced value of 11101.
Under any circumstances, 11101 should be paid at its 100% value and should not be subject to multiple surgery reduction rules.
On the other hand, site-specific skin biopsy codes are subject to multiple surgery reduction rules. However, they all have higher RVUs than 11100 and 11101.
The tables in this column review all of the site-specific skin biopsy codes.
Taking a Closer Look at Site-Specific Biopsy Codes
Let’s take a look at a couple of examples of site-specific biopsy codes in order to get a better understanding.
Example I: A patient with a generalized eruption presents. You do a biopsy on the left arm and the right arm for definitive diagnosis. The same patient also has a suspicious lesion on the left superior helix. During this same visit, you also biopsy the lesion on the ear to rule out basal cell carcinoma. In this case, you should be reimbursed at the full allowable for 69100 and 11101 and at 50% allowable for 11100.
Example II: Patient presents with a suspicious lesion on the right lower eyelid, the left lower lip and the tip of the nose. You go ahead and biopsy all of these areas. In this case, you should get reimbursed at 100% for 67810 and at 50% RVU for 40490 and 11100 since both of these codes are within the multiple surgery reduction criteria.
Example III: A patient presents with whitish suspicious areas on both sides of her labia majora and similar lesions on the anterior tongue. You go ahead and biopsy all three areas. In this case, 56606 is an add-on code to 56605, just like 11101, and cannot be used alone. Therefore, it is not subject to the multiple surgery reduction rules and should be reimbursed at 100% of its allowable. However, 56605 and 41100 are subject to the multiple surgery reduction rules; 41100 will be reimbursed at 100% of its allowable since it has a higher RVU, and 56605 at 50%.
Codes to Use When Waiting for Biopsy Results
As you noticed, in all of the above examples, I used either ICD code 238.2 (Neoplasm of skin, unknown origin) or 782.1 (Non-specific skin eruption) for diagnosis codes. These ICD codes are available for you to use so that you do not have to wait for biopsy results before billing your charges. Not only will this facilitate your payment, but it will also make life much easier for your office staff by eliminating paperwork.
There is absolutely no reason for you to know the diagnosis to code for a biopsy. Regardless of the diagnosis (malignant or benign), reimbursement is the same. Only excision codes are reimbursed at a higher level for malignant lesions.
Actually, if you use the biopsy results as your ICD code for biopsies, you may face this question in a future audit, “Why did you biopsy this lesion, doctor, if you already knew that it was a basal cell carcinoma?” Therefore, it is highly recommended to use these two ICD codes (238.2 or 782.1) for your biopsies.
Avoiding Revenue Losses
As you can see from the examples discussed in this column, it is important to be aware of the site-specific biopsy codes and use them appropriately for both correct coding purposes, as well as to avoid loss of significant revenue.
