Common coding errors can mean lost profits when using EMRs

March 1, 2011

The movement toward quality EMRs for dermatologists is great. It will help providers have better notes and legible accounts of the patient-physician encounter, and it will also help with ICD-9 and CPT coding. In the end, however, providers still have to know what they did in the exam room, realize whether it is a chargeable event, and if it is, choose from an array of codes.

Key Points

The EMR is not the end-all cure-all if the provider is walking down the incorrect coding path. The EMR will only document what buttons the provider touches or keys in, it cannot say, "Hey, you just did an intermediate repair, why didn't you charge for it?"

In this article, I will summarize some of the more important and common coding mistakes made by dermatologists. These mistakes add up and can frequently make the difference between profit and loss, the ability to purchase new equipment, buy a new car or put some extra money away for retirement. Let's make sure you are not giving away your hard-earned profit.

No. 1 on the list of mistakes that can cost practices significant lost revenue is miscoding and billing for a biopsy, when what was actually done was a shave removal or an excision.

Forget intent! Document what you actually did, and bill based on what you documented. If you remove a lesion by either shaving or excision, it is not a biopsy!

Of course, you want to have histological confirmation of what the lesion is. But when that scalpel hits the skin, ask yourself, "What actually occurred?" Did you shave remove the lesion via tangential posturing of the scalpel and in the process try to get as much of the lesion as you could - in essence, complete removal of the tissue? If the lesion comes back benign, you would consider the lesion treated? If you answer yes, then this is a shave removal. Could it grow back? Of course it could. So could a basal cell carcinoma you excised. Just because it could grow back does not change your excision of the BCC to a biopsy. As a result, your documentation should state, "Shave removal of an enlarging, hyperpigmented X.X cm/d lesion of the back. Base of the lesion was electrodesiccated and then pressure dressing was applied."

What if the pathology report comes back as malignant? Then, because you had followed the shave removal by destruction of the base, you can bill the initial "shave removal" as a destruction using CPT codes 17260-17286, depending on the location and size of the lesion. Can you go back and do a more aggressive surgery because of the diagnosis? Of course. You can go back and ED & C the lesion more aggressively, or excise. If either of these options is chosen during the 10-day postoperative period, you just add modifier 58 to the second procedure (e.g., the destruction of the excision).

If you did not destroy the base of the lesion after a shave removal, then you can only charge the shave removal codes (e.g., codes 11300 -11313), regardless of the diagnosis on the pathology report.

Again, you can treat the lesion if you feel additional treatment is needed. If the lesion were malignant or perhaps a dysplastic nevus, you would want to go ahead and treat the lesion by excision. No matter what the subsequent treatment would be, you would not need a modifier on the second, subsequent surgery because the shave removal codes have -0- postoperative days.

Of course, if other surgical services have been done on the day that shave removals were performed, then the postoperative days of those other services could put this second, follow-up procedure into a postoperative period. In this instance, the additional surgery would need modifier 79.

Moreover, if you "remove" a nevus with a punch biopsy, this is not a punch biopsy - it is a full thickness excision. You select a punch that encircles the nevus and you punch it out by going through the full thickness of the dermis into the fat. If the lesion comes back benign, you would consider this fait accomplis. Your documentation should indicate, "Excision down to fat of a 5 mm/d hyperpigmented highly suspicious of a dysplastic nevus or malignant melanoma."

If the lesion is dysplastic or a melanoma, you would do further work and just add modifier 58 if performed during the postoperative period.

Regardless of whether you treat the lesion with shave removal or excision down to the fat, both of these are removals, and not biopsies.

Also, because the diagnosis on the pathology report is one of the determining factors for which CPT code you will bill, always hold shave removals and excisions for pathology confirmation.