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:

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