Category: Article

Continuing our series on some notable changes to CPT this year, codes for biopsies of skin lesions have been expanded.

Prior to this year, we had two codes to represent a biopsy of a skin lesion: CPT 11100 for the first lesion biopsied and CPT 11101 for each additional lesion biopsied. When these codes were created many years ago, they were sufficient to accurately report the types of biopsies being performed at the time. As time has gone on, though, many different techniques for biopsying a lesion have emerged, and the work that goes into performing a biopsy can vary based on the technique used. For that reason, the AMA revised the skin lesion biopsy codes this year to more accurately describe the “method” for obtaining the biopsy.

Below are the new codes and their definitions. Notice that we have a primary or parent code for the first lesion biopsied for each method of biopsy and an add on code for each additional/separate lesion:

• CPT 11102: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); single lesion

• + CPT 11103: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11104: Punch biopsy of skin (includes simple closure when performed); single lesion

• +CPT 11105:  Punch biopsy of skin (includes simple closure when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11106: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); single lesion

• +CPT 11107: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

To understand how to code with the expanded options available for this procedure, it is necessary to first understand some key definitions and rules for their use.

Key Definitions:

• The skin is made up of two layers of tissue. The epidermis is the outermost layer of the skin and provides protection against germs and a water-proof barrier to protect our inside organs. The dermis is the inner layer of the skin which lies between the epidermis and the subcutaneous tissue and provides toughness and flexibility for the skin.
• These different methods of biopsies may take a “partial thickness” sample of the skin (meaning only part of the layers of the skin in the area of the biopsy are removed, such as the epidermis layer only). Alternatively, they may take a “full thickness” sample of the skin (meaning the surgeon cuts through the epidermis and full thickness of the dermis down to the subcutaneous tissue to take a sample that includes all layers of the skin tissues).
• Tangential refers to a slicing motion with a blade. In this type of biopsy, the physician takes a “slice” of the skin and is taking a “partial thickness” sample of the skin lesion, usually taking only the epidermis. The physician may take part of the underlying dermal layer if needed, but in either case, is not cutting full thickness through the skin and taking epidermis and the full thickness of the dermal layer. Some synonyms for tangential include “curetting,” “scooping,” or “shaving” to obtain a biopsy, and you may see these terms used in procedure reports.
• A punch biopsy involves taking a “full thickness” column of tissue from a lesion using a punch tool. Punch tools come in different sizes so you may see a punch tool mentioned along with a size in millimeters (e.g., 12.0 millimeter punch tool was then used to obtain a biopsy)
• An incisional biopsy as the name suggests involves creating an incision with a blade. The incision may either be vertical or may involve cutting out a “wedge” of tissue. This type of biopsy is “full thickness” where tissue through the full thickness of the epidermis and dermis is excised and even the underlying subcutaneous fat may be removed if needed.

Key Guidelines:Now that we understand some key terms used in these code descriptions, we also need to be aware of rules about how the codes should be used.

• These codes can be used for biopsies anywhere in the body as long as the biopsy is of a “skin lesion.” The codes are not restricted to use for a specific anatomic site(s). For biopsy from tissues other than the skin, there are codes throughout the surgery section of CPT to represent those biopsies. For example, if a surgeon documented a biopsy of the anterior two-thirds of the tongue, you would report CPT 41100 rather than one of these skin biopsy codes.

• When coding more than one biopsy during the same case, you can only code one primary/parent code for the most extensive biopsy performed. You would then report all additional biopsies with add on codes. Example: A physician performs an incisional wedge biopsy of a lesion on the right forearm. He then performs a punch biopsy of a second lesion on the upper arm near the shoulder. In this example, you would code CPT 11106 for the most extensive biopsy technique (the incisional biopsy) and code add on code 11105 for the punch biopsy of the second lesion. How did I decide which primary biopsy and add on biopsy code to use? You can determine this both through checking your NCCI edits and your CPT guidelines. If I check NCCI edits between 11106 (first lesion incisional biopsy) and 11104 (first lesion punch biopsy), I see that CPT 11106 has higher total RVUs and is the column 1 (or more comprehensive) code in the NCCI edit. This confirms that the primary code CPT 11106 should be coded and that the punch biopsy should be reported with the add on code using NCCI edits. Your CPT parenthetical notes under these codes can also be useful guides to determining which primary codes the add on may be reported with. For example, underneath CPT 11105 (add on code for each additional lesion biopsied with a punch technique), it tells us to code first 11104 (a first lesion punch biopsy) or 11106 (a first lesion incisional biopsy). Underneath CPT 11107 though (add on code for each additional lesion biopsied with an incisional technique), it tells us to code first CPT 11106 (a first lesion incisional biopsy). So in our example here, we could not have reported CPT 11104 (first lesion punch biopsy) and CPT 11107 (add on code for each additional lesion biopsied with an incisional technique) without violating the CPT guidelines.

• The tangential biopsy codes which again involve a “slicing” of “shaving” motion can appear similar to other CPT codes like shave removals of lesions. To decide whether to code a tangential biopsy code or a shave removal code, look at the intent of the procedure. If the intent is to obtain tissue for a diagnosis/pathology, code the procedure as a tangential biopsy. If the intent is to completely remove the lesion, code the procedure as a shave removal.

• The biopsy codes include “simple closure” when performed. That means that it is not necessary for the surgeon to close the wound after the biopsy in order to use these codes, but that if he does so, and the closure is “simple” you do not get to report a separate code for that closure. The CPT guidelines define simple repair as “one layer closure” (meaning one layer of stitches is placed or techniques such as tissue glue that do not involve the use of stitches are used). In the rare event that a biopsy results in the need for a more extensive intermediate repair (i.e., layered closure where at least one layer is in the subcutaneous tissues or deeper) or complex repair (i.e., more than layered closure involving techniques such as debridement, stents, retention sutures, extensive undermining, or scar revision), you may report a separate CPT code for the repair.

Let’s look at an example together to put these definitions and guidelines into practice:

Example #1: A 30 year old male presents with a raised skin lesion on the right thigh that has grown and changed in color over the past few weeks. He is brought to the procedure room today for tissue diagnosis.

After prep and drape, local anesthetic was applied around the right thigh lesion. A scalpel was used to shave a 0.5 cm strip of epidermal tissue.from the lesion. Bleeding was controlled and patient tolerated the procedure well. He will follow up with me in 1 week for pathology results.

Answer example #1: The bold portions of the procedure note help us with our code selection. First of all we see in the history provided that the intent of the procedure is “tissue diagnosis” confirming this is a biopsy. We also see the indication is a “skin lesion” of the thigh confirming that we should select a code from the skin lesion biopsy codes in the integumentary section of CPT rather than from another section of the CPT manual.

From there, we see the surgeon using a scalpel (a type of blade) to “shave” epidermal tissue only. So the technique for biopsy is a “shave method” and this is a “partial thickness” sample since only the epidermal tissue is taken. These details confirm the biopsy type is tangential. Finally, we see again the physician stating the patient will follow up for biopsy results in 1 week, again confirming intent here is to obtain a biopsy.

Since we have only one skin lesion and that lesion is biopsied using a tangential technique, we will report CPT 11102. 

We are continuing our series on notable changes for CPT in 2019. Another area of the code manual that received a pretty extensive overhaul involved the codes for FNA biopsies. The acronym FNA stands for “fine needle aspiration.” In this technique, the surgeon typically aspirates fluid for biopsy using a fine gauge needle (he/she will often use a 22 or 25 gauge needle in this procedure). The surgeon then withdraws fluid (e.g., from a cyst) or may withdraw clusters of cells from a solid mass and that specimen is sent to pathology to obtain a diagnosis. The term “biopsy” was added to the FNA codes in 2019 to clarify that these codes should not be reported if the intent of the procedure is simply to drain fluid (there are other codes for fluid drainage in CPT). The intent of these FNA biopsy codes is to report use of a fine gauge needle to withdraw a specimen for purposes of biopsy (i.e., getting a diagnosis from the specimen).

In 2018, we only had two codes available for an FNA biopsy: CPT 10021 for an FNA biopsy without imaging guidance and 10022 for an FNA biopsy with imaging guidance. For CPT 10022 for the FNA biopsy with imaging guidance, you then had to add a second code to represent the exact type of imaging guidance used (77002 for fluoroscopy, 76942 for ultrasound, 77012 for CT guidance, or 77022 for MR guidance).

For 2019, though, we now have combination codes that capture FNA biopsy performed using specific types of imaging guidance (e.g., FNA biopsy with fluoroscopic guidance is all captured with a single code). The codes have also been designed to include primary codes for FNA biopsy of the first lesion and add on codes for each additional lesion where FNA biopsy is performed using the same type of imaging guidance.

Let’s start by looking at all of the new codes and their descriptions:

FNA Biopsy Without Imaging Guidance

10021  -Fine needle aspiration biopsy, without imaging guidance; first lesion

+10004 –Fine needle aspiration biopsy, without imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy With Ultrasound Guidance

10005 –Fine needle aspiration biopsy, including ultrasound guidance; first lesion

+10006 –Fine needle aspiration biopsy, including ultrasound guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with Fluoroscopic Guidance

10007 –Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion

+10008 –Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with CT Guidance

10009 –Fine needle aspiration biopsy, including CT guidance;first lesion

+10010 –Fine needle aspiration biopsy, including CT guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with MR Guidance

10011 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

+10012 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

With the creation of these new codes for FNA biopsy, there are a couple of key guidelines to keep in mind:

• You can no longer report imaging guidance codes 77002, 76942, 77012, or 77022 with the FNA biopsy codes to report the imaging guidance used to perform the FNA biopsy itself or a core biopsy on the same lesion during the same encounter. Again the new combination codes already include the work of the FNA biopsy plus the specific form of imaging guidance in a single code. Coding tip: It would be permissible to report one of these imaging codes with an FNA biopsy code if the imaging was used to complete a procedure other than the FNA biopsy or a core needle biopsy on the same lesion during the same encounter.

• If “multiple passes” (i.e., multiple FNA biopsies) are obtained of the same lesion, you will still report only one unit of the FNA biopsy code that describes how that FNA biopsy was obtained. For example, if a surgeon performs an FNA biopsy under CT guidance for a nodule in the left thigh and he makes four passes into that nodule during the procedure to ensure he obtains adequate tissue for pathology, you will code CPT 10009 with only 1 unit. Even though four “passes” were made, he is biopsying just one lesion so you only code 1 unit of the CPT.

• When multiple lesions are addressed with FNA biopsy during the same encounter and all lesions are biopsied using the same type of imaging guidance, you report the primary code for the first lesion biopsied and report the add on code for the second and all additional lesions. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid also under ultrasound guidance, you will code CPT 10005 for the first nodule and CPT 10006 for the second nodule.

• When multiple lesions are addressed with FNA biopsy during the same encounter but lesions are biopsied using different types of imaging guidance, you report the primary code for the first lesion biopsied, picking the primary code that accurately describes the type of imaging guidance used, and then you report a second primary CPT code for the additional lesion biopsied using a different type of imaging guidance. Modifier 59 (or modifier XS if your payer like Medicare accepts the EPSU modifiers) will be required on the second primary CPT code to indicate that more than one site was biopsied. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid under fluoroscopic guidance, you will code CPT 10007 for the nodule biopsied using fluoroscopic guidance and CPT 10005 with modifier 59 (or modifier XS if the payer like Medicare accepts the EPSU modifiers) for the second nodule biopsied under ultrasound guidance. The coding is changed in this scenario because each nodule was biopsied using a different type of imaging guidance. Coding tip: I decided which CPT code needed the modifier 59 based on the NCCI edits. The modifier 59 would go on the column 2 code (i.e., the potentially bundled code in the NCCI edit pair). You can download a copy of the NCCI edit tables from Medicare’s website at the following link: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. When you get to the website, download all files that start with “Practitioner PTP Edits v25.0” (there are four files in total). You can also check edits in online coding software like 3M, Encoder Pro, and Supercoder (many coders find this to be an easier method of checking their edits). Just be sure to apply the modifier 59 (or XS) to your column 2 code.

I hope this article helps you to understand the changes for these codes in 2019 and how to use these codes correctly. If you have any questions about this topic or any of the new 2019 CPT codes that you would like to hear more about, head over to the “contact” tab and send me your question. I am always happy to hear from my readers and provide content that will help you in your daily work.

Many times when I’m working with coders and refer to a guideline that lead me to my conclusion on how to code a specific procedure, the coder will ask me how they can find the guidelines I’m referencing for themselves. One of the first keys to being a successful coder is building your library of coding resources that will help you along the way. This article is dedicated to sharing with you all some of the resources that help me with my daily work.

• The CPT guidelines: While this may seem like an obvious one, it’s amazing how many times I see a coder make an error on a case because they weren’t aware of the CPT guidelines for that code. The CPT guidelines include the paragraphs of information that appear before a particular range of CPT codes or the parenthetical guidelines that might appear underneath different codes throughout the manual to guide us on appropriate use of the codes. The paragraphs of information throughout CPT often provide key definitions to help us better understand the intent of the codes while the parenthetical guidelines usually provide key rules for how the codes should be used (e.g., notes telling us to code also a second CPT to represent two procedures commonly performed together or to refrain from coding two CPT codes together based on the rules of use for that code).

• The Coder’s Desk Reference: The Coder’s Desk Reference is an Optum product that provides lay descriptions for all CPT            codes. These lay descriptions provide an explanation of that particular code and the procedures that would be included in that code from the start of the procedure to the end of the procedure in easy to understand language. For example, CPT 49560 which is for open repair of an initial ventral or incisional hernia describes how the physician makes an open incision overlying the hernia, reduces or removes the hernia sac, closes the facial defect (the hernia defect itself), and then closes the abdominal wall in layers. The goal of this resource is to help surgery coders specifically know if they are picking a code that accurately reflects the procedure their surgeon performed (the coder is able to “line up” some of the language from the operative report with the language in the lay description to see if the two are a match). This tool can also be helpful to understanding what parts of a procedure are integral  (meaning they are a routine part of the procedure and should not be coded with an additional CPT code(s)). The Coder’s Desk Reference is available for purchase as a stand-alone product through the publisher Optum: Coder’s Desk Reference. It is also available through other third-party websites and is often offered as part of coding software packages such as Optum Encoder Pro or Supercoder.

• CPT Assist:  CPT Assistant (known as CPT Assist for short) is a publication from the American Medical Association (AMA). The AMA is the governing body that publishes the CPT manual each year. CPT Assist is a publication where the AMA answers frequently asked questions from coders and physicians or where they explain guidelines for CPT codes/topics that aren’t abundantly clear in the CPT manual. Often, the AMA will answer a coding question and also provide a clinical vignette to illustrate the correct use of the CPT code. This publication is available for direct purchase from the AMA: CPT Assist. It is also available as an add on module for purchase as part of coding software packages such as Optum Encoder Pro.

• NCCI Edits: The National Correct Coding Initiative (NCCI) edits are published by Medicare each quarter (in January, April, July, and October). The purpose of the NCCI edits is to prevent inappropriate reporting of procedures that are considered a routine part of the main procedure being performed. When coders and physicians report multiple CPT codes when one or more of those codes is considered a routine part of the main procedure, the practice is know as unbundling. While the NCCI edits are a Medicare product and Medicare Administrative Contractors processing claims will always follow the NCCI edits, many commercial carriers also follow the NCCI edits (you may find some small payers that do not follow NCCI and develop their own editing policies, but those payers are growing more rare as NCCI has become a nationally-accepted standard for correct coding and referenced by many non-Medicare payers). You can usually check your payer contracts to see if they are following NCCI or find this information through a simple Google search (e.g., “does United Healthcare follow NCCI edits?”) The NCCI edit tables can be downloaded from the Medicare website each quarter:  NCCI Edit Tables. These edits can also be checked in coding software such as Encoder Pro and Supercoder which offer built-in CCI edit check tools.

• NCCI Policy Manual: The NCCI Policy Manual is a tool designed to be used in conjunction with the NCCI edit tables. This policy manual is published by Medicare and updated each January. The NCCI Policy Manual explains the reason for many of the edits that exist in the NCCI edit tables. The policy manual also explains certain correct coding rules for which no edits exist. The introduction chapter to the NCCI policy manual states that the NCCI edit tables are designed to represent the most common forms of unbundling that exist, but even in the absence of an NCCI edit, providers and coders are expected to code correctly. To explain that statement further, it is not good enough to simply check your NCCI edits and report two codes together simply because no edit exists. You must consider all coding guidelines and policies including the CPT guidelines and the rules outlined in the NCCI Policy Manual in your coding. The NCCI Policy Manual is available for download from the CMS website: NCCI Policy Manual. The current manual is titled “NCCI Policy Manual for Medicare Services – effective January 1, 2018” and can be found in the “downloads” box once you arrive at the website.

• CMS Modifier 59 Article: As important as it is to know whether an NCCI edit exists between two codes, it’s equally important to know why that edit exists and when it would be appropriate to bypass the edit with a modifier 59 or one of the new EPSU modifiers from Medicare (I will talk more about these EPSU modifiers in a future article). The CMS Modifier 59 Article is a key resource to understanding NCCI edits and when you would and would not bypass those edits. The article stresses the fact that just because the edit between two codes allows for a modifier to bypass the edit does not mean you should automatically do so.
  The article also provides some helpful examples of when you could unbundle two codes in an NCCI edit pair. This article is available for download from the CMS website: Modifier 59 Article. When you arrive at the website, scroll down to the downloads box and click on “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Services – Updated 11/15/17.”

• CMS Examples of NCCI Edits: Another great resource I found from CMS is a 49 page document explaining different reasons NCCI edits may exist and giving clinical examples of those types of edits and appropriate coding. Each NCCI edit is assigned a “reason” for potential bundling in the NCCI edit tables (e.g., standards of medical/surgical practice, more extensive procedure, misuse of a column 1 with a column 2 code, etc.). Each of these reasons has a specific definition in CMS policy and helps us to better understand why the edit exists which in turn can help us know when to bypass the edit and when the edit actually applies to our report and scenario and should not be bypassed. This tool is available for download from the CMS website at the following link: NCCI Edit Examples

• CMS Claims Processing Manual Chapter 12: The CMS Claims Processing Manual contains many of the guidelines that Medicare Administrative Contractors (MACs) apply when they are processing claims. Chapter 12 is particularly helpful for surgery coders because it contains the rules for co-surgery, assistants at surgery, billing for mid-level providers (NPs/PAs), teaching facility rules where physicians involve residents in their surgeries, and many other surgery-specific topics. This resource is available for download from the CMS website: Claims Processing Manual.

• Medically Unlikely Edits: The Medically Unlikely Edits (MUEs) are also published by Medicare each quarter (in January, April, July, and October). These edits let providers and coders know how often a code is typically expected to be billed by the same physician providing care to the same patient on the same date of service. In addition to looking at the MUE itself which tells you how many times a code would generally be reported on the same date by the same provider, you should also check the MAI indicator (which is the reason the MUE edit exists). This indicator is also referred to as the MUE rationale and lets you know when you may exceed the MUE for a particular code and when the edit is binding. The three MAI indicators for MUE edits are as follows:

1 – Line item edit: This type of edit represents the maximum number of units of a code that may be reported on a single line on a claim. To bypass this edit if you need to report units in excess of the MUE, report the code on more than one line of the claim and link the maximum number of units allowed by the MUE to each line of the claim. For example, if you are reporting a code with an MUE of 3 and an MAI indicator of “line item edit,” and you need to report 6 units of the code based on documentation report the code once on the first line of the claim with units of 3 and then report a second line of code with the same CPT and the remaining 3 units.

  2 – Date of service edit: This type of edit represents the maximum number of units of a code that may be reported by the same  physician for the same patient on the same date of service. These edits are considered “binding” on providers and contractors     processing claims based on anatomy or the definition of a code. In other words, you absolutely cannot code in excess of the MUE for a code with this MAI indicator (to do so is considered a coding error per Medicare guidelines).

 3 – Date of service edit: This type of edit represents the maximum number of units of a code that Medicare expects to be reported by the same physician for the same patient on the same date of service. This edit is similar to the MAI indicator of 2, but unlike that edit, this type of MUE edit may be exceeded when documentation supports coding in excess of the MUEs for a particular CPT code(s). Be prepared to submit documentation supporting the fact that exceeding the MUE for the code is appropriate since Medicare views reporting more units than that typically allowed to be the exception not the norm.

The MUE edit tables which contain the MUEs and the MAI indicators is available for download from the CMS website: MUE Edit Tables. When you arrive at the website, scroll down to the “downloads” box and click on the Practitioner MUE tables link for the current quarter.

I hope you find these resources helpful! How about you – what coding resources do you find helpful when coding surgical and diagnostic procedures? Share your favorite resources in the comments. Coding is a team sport, and you never how a great resource you have discovered might help a fellow coder.