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Topic: Correctly code general surgery for lesion removal

Ambulatory Surgery Reimbursement Update, April 21, 2008

Traditionally, general surgeries for lesion removal are either upcoded or downcoded, and this common coding mistake results from documentation that lacks necessary details.

Educate surgeons about the current procedural terminology (CPT) coding guidelines so they know what information they need to clearly document for proper coding, says Joanne Schade-Boyce, RDH, MS, CPC, ACS, vice president of FairCode Associates, LLC, in Towson, MD.

The coder needs to know the lesion diameter plus the most narrow surgical margins, but surgeons frequently neglect to provide this information to the coder. This often compels coders to refer to the pathology report and code from that, which violates CPT guidelines that state the surgeon must measure the lesion prior to excision.

“In a recent audit of a dermatology group, dermatologists were under the impression that they only have to give surgical margins for malignant lesions,” Schade-Boyce says. “However, the rules state that you have to give surgical margins for both malignant and benign lesions.”

Instead of coding from the pathology report, coders must query the surgeons, who then have to refer back to their notes, made when they saw the patient before surgical scheduling.

Communicating the CPT guidelines to physicians can make a big difference in not only coding accurately, but the timeliness of the claim.

When coding lesions, coders have to choose between the integumentary system and the musculoskeletal system. Many common coding mistakes result from assigning CPT codes from the wrong system, says Schade-Boyce.

Coders should consult the guidelines in the CPT Manual and CPT Assistant, which help determine which system to use for different scenarios.

Editor’s note: This topic is from the March 2008 issue of Ambulatory Surgery Coding & Reimbursement Insider.

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