Thursday, June 28, 2012

11443 or 11441? Measure Appropriately and Add $54 to This Excision Claim

Timing is everything for medical coding accuracy.

Waiting for the pathologist to measure an excised lesion might cost your dermatologist plenty. However not waiting for the pathology report could load the patient with a misdiagnosis. Use these tips to make certain the correct diagnosis and medical coding -- and ethically maximize pay.

Rule # 1 -- You Must Measure First

You must select the correct lesion excision size code which is based on the dermatologist's report. In case the dermatologist doesn't measure the lesion prior to the cutting, he's also cutting his reimbursement in half.

After the specimen is in the jar, the specimen reduces to half its original size. In case the dermatologist doesn't write the new size in the note, the coder has to certain code based on the lesser excision size listed in the pathology report. However, that will cost the practice a lot of money.

Add it up: You must define the lesion size for medical coding purposes based on the grounds of the largest lesion diameter and over two times the narrowest margin.

Grasp Diagnosis for Path Report

You must always select the malignant or benign excision code based on the conclusions of the pathology report, even in case the dermatologist does not have that data at the time of surgery. The pathology report proposes the conclusive diagnosis that serves as the basis for the selection of CPT code for excision.

Proper protocol: You must always select the excision CPT code after the pathology report returns. In case the pathology displays malignancy, you should code the procedure as excision of a malignant lesion

Review Anatomic Location

Subsequent to receiving the pathology report, evaluate the documentation for excision size and location. After that it's all about location from the anatomical site to ensure the practice is getting all revenue.

Each anatomical group has lesion excision sizes varying from small to large lesions.

Example: As per the documentation reads, excised face lesion 1.0 cm length by 2.0 cm width lesion, taking 0.2 cm margins. The pathology report comes back benign, and then you mark 11443 (Excision, other benign lesion including margins, except skin tag [unless listed else-where], face, ears, eyelids, nose, lips mucous membrane; excised diameter 2.1 to 3.0 cm) for the 2.4 cm codeable size ([2.0 lesion diameter] + [0.2 x 2 margins]). In case, though, the dermatologist had failed to document the size and the pathology report measured a 1.0 cm lesion plus 0.1 margins, you could use only
CPT code 11442 ( . . . excised diameter 1.1 to 2.0 cm), leading to a loss of $35 (Code 11443 pays $207.59, while 11442 pays $172.93 for non-facility national amount using 36.8729 conversion factor).

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