How to Document and Code Lesion Removal – Review of Ophthalmology

The number, histology, location, removal method – a host of factors can come into play when billing these procedures.

This article addresses the following questions:

• Is there a method to determine the best CPT code for lesion removals?
• Do lesion removal codes have a global period, and may we file for an office visit on the day of the removal?
• What is the best way to document the procedure?
• What is the difference between the three CPT codes that describe a chalazion removal?
• Is it appropriate to use CPT code 67840, excision of lesion of eyelid (except chalazion) without closure or with a simple direct closure, for all eyelid lesions?
• If 67840 is not appropriate and the lesion removal is only skin, what codes should be considered?
• How is the size of the excision calculated?
• If the surgeon is unsure of the histology of the skin lesion and submits the specimen to pathology, can this be coded and filed on the date of service?
• What is the difference between an excisional biopsy and a biopsy?
• Does Medicare reimburse removal of benign lesions?
• Is closure of the wound or an adjacent tissue transfer separately billable?
• Do third-party payers reimburse for the removal of skin tags?
• Are there additional ophthalmic surgical codes to consider?

This article was published in Review of Ophthalmology’s Medicare Q & A column, which is written by Corcoran’s Vice-President, Donna McCune, CCS-P, COE, CPMA. To view the entire article in Review of Ophthalmology, click on the link below:

http://www.reviewofophthalmology.com/content/d/medicare_q___and___a/i/3699/c/61578/