Derm CodingConsult

Published by the American Academy of Dermatology Association

ICD-10-CM Implementation
Delay: Dermatology Practices
Receive a Lifeline
The AAD learned in early April that the implementation date
had been postponed for another full year. This new delay
came as part of H.R. 4302, the Protecting Access to Medicare Act of 2014 which was signed into law by President
Obama. Section 212 of the Act includes language stipulating
that The Secretary of Health and Human Services may not,
prior to Oct. 1, 2015, adopt ICD-10 codes as the standard for
code sets.
At the time the bill was signed into law, there were six
months remaining in the original anticipated implementation timeline date of October 1, 2014. Many dermatologists
and other specialty physicians had been working diligently
in learning the ins and outs of the new ICD-10-CM code
sets, in order to meet all the necessary requirements to
successfully implement ICD-10-CM by the initial implementation date.
This delay will allow those who were behind in the preparation phases to ramp up their efforts and assess areas
that need to be improved upon. Those who were on target
should look at this time as a time to continue efforts and
enhance their ICD-10-CM coding dexterity skills.
Stay Focused and Continue Preparing
While this delay was unexpected, it is very important to
stay the course and continue to anticipate the arrival of ICD10-CM implementation and to be prepared with continued
education.
The additional time delay should be used wisely and
constructively to allow dermatology practices time to take
another look at their implementation timeline (and budget)
to reevaluate how they are approaching this change in their
day to day activities. For example, a quick assessment of billing forms, superbills, patient encounters, progress notes and
electronic health care record template readiness are all good
places to start working on creating efficiencies for the future.
Doing these simple exercises will allow physicians and staff
members to stay focused and find motivation for improvement in specific areas during this additional timeframe.
Below are helpful tips your practice should follow during
this new additional time delay:
Continue to work with the original implementation timeline in mind if you were on track for October 1, 2014.
CPT only 2013 American Medical Association. All Rights Reserved.

Volume 16
[ Volume
|
Number
18 | Number
1 | 2 |Spring
Summer
2012
2014 ]

View an example of the implementation timeline

at http://www.aad.org/members/practice-and-advocacy-resource-center/payment-and-reimbursement/
coding-resource-center/icd-10
Use the extended timeline to practice dual diagnosis
coding to your practice. Take a few of your charts and
review the medical record documentation. Code some
of these encounters in both ICD-9-CM (submit these
for payer payment) and ICD-10-CM (to establish your
ICD-10-CM accuracy level);
Use the extended timeline to improve ICD-10-CM
accuracy with introduction of clinical documentation
improvement (CDI) to assist with ICD-10-CM coding
accuracy. Additional practice with ICD-10-CM will
improve your coding efficiency and confidence for
increased productivity;
Identify any gaps in documentation that lead to reporting nonspecific codes and work to remedy these gaps
prior to the implementation deadline.
Use the extended timeline to review your current
ICD-9-CM super bill and crosswalk these codes to
ICD-10-CM at the highest specificity to ensure a seamless transition. v

Contents
ICD-10-CM Implementation Delay:
Dermatology Practices Receive a Lifeline . . . . . . . . . . . . 1
Letter from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Wound Debridement: Clarifying Common
Terminology & Coding Questions . . . . . . . . . . . . . . . . . 2-4
FAQs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Dangers of Upcoding Using an EHR . . . . . . . . . . . . . . . . 5

CMS New Changes to IHC Coding. . . . . . . . . . . . . 5-6

IHC Coding Examples. . . . . . . . . . . . . . . . . . . . . . . 6-7
2012 PQRS Reporting Comparison . . . . . . . . . . . . . . 7
In the Know. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

IMPORTANTPlease Route to:

___ Dermatologist ___ Office Mgr

___ Coding Staff ___ Billing Staff

Derm Coding Consult: Summer 2014

Letter from the Editor

Dear Derm Coding Consult Reader:
The legislative delay of ICD-10-CM until October 1,
2015 has given dermatology practices an opportunity to
reevaluate their training and implementation plan. CMS
is encouraging practices to continue with the current
educational programs and to be ready for 2015. This
summer is a great time to develop your action plan if
you havent already.
This issue contains an informative article on immunohistochemistry (IHC) billing changes for Medicare.
Medicare has created codes G0461 and G0462 to
report a professional, technical or global charge for
qualitative IHC testing for a Medicare beneficiary on
and after January 1, 2014. Additional information on
commercial billing, as well as, a comprehensive IHC
Q&A section is also included.
Your feedback and input is critical in developing and
maintaining this valuable resource. I appreciate all
of your comments and suggestions. Staff is working
together to ensure that Derm Coding Consult provides
our members with information that is current, up-todate, and relevant to their practice.
Best,

Cynthia A. Bracy, RHIA, CCS-P

Wound Debridement:
Clarifying Common Terminology
& Coding Questions
In the last few years, the American Medical Association
(AMA) has been actively clarifying and revising the coding
information in the CPT coding manual. New guidelines
have been established for wound debridement and are
listed in the Integumentary section of the manual.. There
are new aspects regarding the wound surface size and
depth that need to be kept in mind when reporting these
codes.
Below is a quick synopsis of how the documentation
needs to be reflective of the procedure performed
Surgical debridement is the excision or wide resection of all dead or devitalized tissue, possibly including
excision of the viable wound margin. This is usually
carried out in the operating theatre under anesthesia
by a surgeon. It is frequently used for deep tissue
infection, drainage of abscess or involved tendon
sheath, or debridement of bone.
Sharp debridement is the removal of dead or foreign
material just above the level of viable tissue, and is
performed in an office setting or at the patients
bedside with or without the use of local anesthesia.
Sharp debridement is less aggressive than surgical
debridement but has the advantage of rapidly improving the healing conditions in the ulcer. These typically
are the services of recurrent, superficial or repeated
wound care.
Blunt debridement is the removal of necrotic tissue
by cleansing, scraping, chemical application or wet to
dry dressing technique. It may also involve the cleaning
and dressing of small or superficial lesions. Generally,
this is not a skilled service and does not require the
skills of a therapist, nurse, or enterostomal nurse.
see DEBRIDEMENT on page 3

Editorial Advisory Board

Jeremy Bordeaux, MD, FAAD

ASDS Alternate Rep to AMA CPT Advisory
Committee

Coding & Reimbursement Task Force Members

Maryam Mandana Asgari, MD
May J. Chow, MD, FAAD
Daniel T. Finn, MD, FAAD
David E. Geist, MD, FAAD, Chair
Lawrence J. Green, MD, FAAD
Monica L. Halem, MD, FAAD
Carl Martin Leichter, MD, FAAD
David Kouba, MD, FAAD
David Michel Pariser, MD, FAAD
Karina M. Parr, MD
Ben M. Treen, MD, FAAD
Simon S. Yoo, MD, FAAD

David Pharis, MD, FAAD

ACMS Rep to AMA CPT Advisory Committee

Cynthia A. Bracy, RHIA, CCSP

Editor, Derm Coding Consult

Ed Wantuch, Design Manager

Ana Maria Bustos

Assistant Editor, Derm Coding Consult

Alexander Miller, MD, FAAD

AAD Rep. to AMA CPT Advisory Committee
Ann F. Haas, MD
AAD Alternate to AMA CPT Advisory Panel
Murad Alam, MD, FAAD
ASDS Rep. to AMA/CPT Advisory Committee
Stephen P. Stone, MD, FAAD
SID Rep. to AMA/CPT Advisory Committee

Nicole Torling, Lead Designer

Theresa Oloier, Editorial Designer

Peggy Eiden, CPC, CCSP, CPCD

Contributing Writer
Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC
Contributing Writer
Scott Weinberg
Contributing Writer

Editors Notes:
The material presented herein is, to the best of our knowledge accurate and
factual to date. The information and suggestions are provided as guidelines
for coding and reimbursement and should not be construed as organizational policy. The American Academy of Dermatology/Association disclaims
any responsibility for the consequences of actions taken, based on the information presented in this newsletter.
Mission Statement:
Derm Coding Consult is published quarterly (March, June, September and
December) to provide uptodate information on coding and reimbursement
issues pertinent to dermatology practice.
Address Correspondence to:
David E. Geist, MD, FAAD Editorial Board Derm Coding Consult
American Academy of Dermatology Association
P.O. Box 4014 Schaumburg, IL 601684014

Richard Martin
Contributing Writer

Derm Coding Consult: Summer 2014

CPT only 2013 American Medical Association. All Rights Reserved.

Wound Debridement:
Clarifying Common Terminology
& Coding Questions
continued from page 2

Enzymatic Debridement is debridement with topical

enzymes, used when the necrotic substances to be
removed from a wound are protein, fiber and collagen.
The manufacturers product insert contains indications,
contraindications, precautions, dosage and administration guidelines; it would be the clinicians responsibility
to comply with those guidelines.
The wound debridement codes (11042-11047) were most
recently revised in 2011. These codes cover extensive
excisional debridement by a sharp removal of devitalized
tissue, necrosis, or slough that includes cutting outside
or beyond the wound margin to healthy tissue.
The selection of the codes is based specifically on the
depth of the procedure and surface of the wound. A
debridement performed in conjunction with another
procedure is usually included in that procedure.
Although the procedure codes have been simplified to
include the wounds depth and surface area, there still is
confusion over which codes to report appropriately. When
selecting debridement codes, the depth and surface area
of the tissue removed must be known and documented .
The levels of debridement include the following:
Code 11042 - Debridement, subcutaneous tissue
(includes epidermis and dermis, if performed); first
20 sq. cm or less - includes debridement of the first 20
sq. cm or less of subcutaneous tissue debrided regardless of the number of wounds debrided at this depth.
It includes the debridement of epidermis and dermis, if
performed. Code 11042 is reported by the total wound
area debrided at the deepest level, not for each wound
debrided when multiple wounds are involved.
#+11045 ; each additional 20 sq. cm, or part thereof
(List separately in addition to code for primary procedure) is an add-on code which is out of CPT code
sequence.
Code 11043: Debridement, muscle and/or fascia
(includes epidermis, dermis, and subcutaneous
tissue, if performed); first 20 sq. cm or less, includes
debridement of the first 20 sq. cm or less of muscle and/
or fascial tissue regardless of the number of wounds
debrided at this depth. It includes debridement of epidermis, dermis, and subcutaneous tissue, if performed.
Code 11043 is reported by the total wound area debrided
at the deepest level, not for each wound debrided when
multiple wounds are involved.
#+11046 ; each additional 20 sq. cm, or part thereof
(List separately in addition to code for primary procedure), is an add-on code which is out of CPT code
sequence.
CPT only 2013 American Medical Association. All Rights Reserved.

Code 11044: Debridement, bone (includes epidermis,

dermis, subcutaneous tissue, muscle and/or fascia,
if performed); first 20 sq. cm or less; includes debridement of the first 20 sq. cm or less of bone tissue debrided
regardless of the number of wounds debrided at this
depth. It includes debridement of epidermis, dermis,
subcutaneous tissue, muscle, and fascia, if performed.
Code 11044 is reported by the total wound area debrided
at the deepest level, not for each wound debrided when
multiple wounds are involved.
#+11047 ; each additional 20 sq. cm, or part thereof
(List separately in addition to code for primary procedure),
is an add-on code which is out of CPT sequence.
The AMA CPT clarified the term, part thereof which
allows an add-on code to be reported with the primary if the
sum of both is at least one square centimeter more than
the primary code maximum. For example, if the wound is
21 sq. cm for a subcutaneous debridement, the procedure
should be reported as 11042 x 1 for the first 20 sq. cm and
11045 x 1 for the additional remaining 1 sq. cm.
The documentation must include a detailed report of the
type and depth of the tissue removed and the measurement of the surface area debrided in square centimeters.
The documentation should detail the debridement method
used (i.e. sharp debridement).
Multiple wound depths are reported differently. The AMA
CPT Code Book discusses multiple wounds at different
depths and surface areas. Each must be identified first
by depth, and then by surface area. Each depths surface
area is added together no matter the anatomical site. For
example, a physician performing a 10 sq. cm subcutaneous tissue debridement of a heel wound to bone wound
and a separate 5 sq. cm debridement of a thigh wound
into subcutaneous tissue. Codes 11042 and 11044 would
be used due to the different depths of the wound debridement performed.
Active wound management care codes (97597 & 97598)
are reported when a debridement is performed only on the
skin, epidermis, and/or dermis to remove devitalized tissue.
The detail of each of these codes is listed below to provide
additional clarification:
97597 - Debridement (e.g., high pressure water jet
with or without suction, sharp selective debridement
with scissors, scalpel and forceps), open wound, (e.g.,
fibrin, devitalized epidermis and/or dermis, exudate,
debris, biofilm), including topical application(s), wound
assessment, use of a whirlpool, when performed
and instruction(s) for ongoing care, per session, total
wound(s) surface area; first 20 sq. cm or less.
+ 97598; each additional 20 sq. cm, or part thereof (List
separately in addition to code for primary procedure)
Although these are usually ongoing care procedures, these
codes are reported per date of service using the total
wound(s) surface area size as the determinant of the appropriate code.
see DEBRIDEMENT on page 4

Derm Coding Consult: Summer 2014

Wound Debridement:
Clarifying Common Terminology
& Coding Questions
continued from page 3

Selective debridement is the removal of a specific, targeted

area of devitalized or necrotic tissue. Occasional bleeding
and pain may occur, but the application of a topical or local
anesthetic does not change a wound care management
procedure to a surgical debridement. Selective debridement includes selective removal of necrotic tissue by
sharp dissection, including scissors, scalpel, and forceps.
Selective debridement should only be performed under the
specific order of a physician.
Both the active wound care and debridement codes have
zero global surgical days but most Medicare Local Coverage Determination (LCD) limitations state that the surgical
debridement services should only be reported once a week.
Medicare Administrative Contractor, First Coast Services
Options (FL, PR & VI) LCD 29128 clarifies that the
11042-11047 codes are considered extensive surgical
debridement, whereas the 97597-97598 are sharp debridement to a targeted devitalized wound although not as
extensive and that can be performed by ancillary staff with
a specific scope of practice and training.
Their explanation is detailed below:
Surgical debridement codes (11042-11047), as performed
by physicians and qualified non-physician practitioners
licensed by the state to perform those services, are
reported by depth of tissue removed and by surface area
of the wound. These codes can be very effective but
represent extensive debridement, often painful to the
patient, and could require complex, surgical procedures
and sometimes require the use of general anesthesia.
Surgical debridement will be considered as not medically necessary when documentation indicates the
wound is without infection, necrosis, or nonviable tissues
and has pink to red granulated tissue.
CPT codes 97597 and 97598 are used for the removal
of specific, targeted areas of devitalized or necrotic
tissue from a wound along the margin of viable tissue.
Occasional bleeding and pain may occur. The routine
application of a topical or local anesthetic does not
elevate active wound care management to surgical
debridement. Selective debridement includes removal
of necrotic tissue by sharp dissection including scissors,
scalpel, and forceps and by high pressure water jet.
It is important to note that patient wound care training and
dressings are not a Medicare benefit; they are included
as part of the surgical package. Any costs associated with
dressing changes may not be passed on to the patient
even if an Advance Beneficiary Notice (ABN) was signed.

As with all procedures, there are certain documentation expectations that must be met. The operative or
procedure note should include the anatomical site
treated which may include a photograph or drawing,
surgical method performed, if anesthesia was required,
tissue type removed with its severity, odor and depth
and surface area of the wound with the post-operative
instructions.
Other important facts such as: was pathology performed,
was the patient compromised, and status and timing
of the treatment expectation for healing should all be
detailed in the documentation.
For more information see CMS Wound care and
Debridement LCDs: http://www.cms.gov/medicare-coverage-database/search/search-results.aspx?CoverageSelec
tion=Local&ArticleType=All&PolicyType=Final&s=All&CptH
cpcsCode=11042&bc=gAAAAAAAAAAAAA%3d%3d&=& v

FAQS
Wound repairs
In recent weeks there have been an increased number
of inquiries from dermatologists regarding denials for
providing multiple repairs with or without grafts. Normally,
when two or more repairs or grafts of the same anatomical classification are performed on the same day, they are
added together and reported as one code. For example,
two excisions on the arm, 11401 and 11403, are reported
separately but only one repair was performed the correct
code to report is 12032.
The AMA, through the CPT, has created new guidelines
for wound repairs when more than one classification of
wounds is performed. The complicated repair procedure is to be reported as the primary procedure first,
followed by the less complicated repair as the secondary
procedure. The less complicated repair from another classification is to be reported with a Modifier-59.
For example, a simple repair of a 2.6 cm wound on the
neck is performed during the same visit as an intermediate repair of a 2.7 cm wound on the scalp. The appropriate
codes to report are 12032 followed by 12002-59 plus the
excisions codes. These codes are subject to the multiple
surgical reduction but for most carriers, modifier -51 is
not a requirement. However; modifier -59 on the less
complicated procedure may be necessary. Check with
the most recent NCCI edits found on CMS website:
www.cms.gov/NCCI
Q. I have encountered some payment denials with
Novitas when billing repairs involving two graphs
A. CPT Code 15120 description is spilt skin graft, scalp,
face, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet and or multiple digits; first 100 sq. cm
or less
see FAQ on page 5

Derm Coding Consult: Summer 2014

CPT only 2013 American Medical Association. All Rights Reserved.

FAQS
continued from page 4

CMSs decision to allow only one 15120 is correct. In

2012, the skin graft codes were revised by the AMA
CPT and it was decided that these multiple, same
anatomical classifications would be added together
and reported as one code.

Q. A patient presented to our office with a 14 cm

clinically benign growth. The doctor performed a
4 cm excisional biopsy removing part of the lesion.
Should this be coded as an excision or a biopsy?
A. If only part of the lesion was removed from a 14 cm
lesion, the intent seems to be a biopsy. The removal
of the rest would be dependent on medical necessity.
Q. Can a practice fire a chronic no-show patient?
A. Yes. Document in the medical chart each no-show
date and what reminders were given to the patient
for the upcoming appointments. Check with the
patients carrier for their patient termination regulations, send the patient, and send the insurance a 30
day letter of care advising them of the termination of
care. Include referrals to where they can establish
continued care. v

Dangers of Upcoding
Using an EHR
One of the dangers of using an EHR is the potential
to upcode evaluation and management (E&M) levels
through the use of auto-populated data fields, automated
coding application, and copy and paste functionality.
Another danger is repetitive, inconsistent, or identical
chart notes. Duplicative chart notes do not enhance
the care or treatment of patients over time. Physicians
tend to ignore standard entries that appear to be form
driven and lacking unique patient-specific observation.
This charting style may also lead to questions of medical
necessity. The documentation focused E&M level drives
physician reimbursement.
Duplicative and over-documented chart notes can trigger insurance denials or audits. When using automated
coding functionality features within the EHR system,
the E&M level will be based on all of the documentation
entered. It is important to remember that copy and paste
documentation, as well as newly charted documentation
are considered in the leveling of E&M visits when utilizing automated coding functionality.
The risks associated with automated coding functionality
are:

Including documentation not relevant to the current visit.

Including documentation already reimbursed in the
calculation for a previous E&M visit.
Not having demonstrated the medical necessity to
reevaluate the prior documentation during the current
visit.
MITIGATE THE RISK OF UPCODING:
Reach out to vendors - ask EHR vendors to address
implementation of copy and paste and the use of
auto-populated templates. These features may be
optional with the capability of disabling them to lower
risk. You may want to consider disabling the copy and
paste functionality and the automatic evaluation and
management level coding functionality.
Perform periodic or random chart audits - select
several charts from each dermatologist in the practice
to audit for medical necessity and appropriate E&M
level billing. This process should become a part of
your compliance plan to monitor your EHR system on
a regular basis.
If medical necessity issues and/or upcoding are discovered - provide education on the audit findings and
perform another audit within a 3-6 month period posteducation to re-evaluate.
Educate staff on EHR risks - provide education on EHR
risks and appropriate use of templates, auto-populated
data fields, automated coding, and copy and paste
functionality. v

CMS New Changes to

IHC Coding
As of Jan. 1, 2014, the Centers for Medicare and Medicaid
Services (CMS) has deemed CPT codes 88342 and 88343
not valid for Medicare purposes when billing for qualitative immunohistochemistry (IHC) and will deny payment if
billed on a claim.
Instead, Medicare has created codes G0461 and G0462
specifically for their use. To report a professional, technical
or global charge for qualitative IHC testing for a Medicare
beneficiary on and after January 1, 2014, you must use
the appropriate HCPCS Level II code with the appropriate
modifier where applicable:
G0461 Immunohistochemistry or immunocytochemistry,

per specimen; first single or multiplex antibody
stain;
+G0462 each additional single or multiplex antibody stain

(List separately in addition to code for primary
procedure)
Currently, CMS pays for just one unit of service for IHC
cocktail stains. With the new directive, CMS is now indicating that IHC should be billed based on the primary stain,
not on the basis of the number of individual antibodies that
see IHC CHANGES on page 6

CPT only 2013 American Medical Association. All Rights Reserved.

Derm Coding Consult: Summer 2014

CMS New Changes to

IHC Coding
continued from page 5

can be detected and analyzed using that stain. For example,

Medicare can be billed for one unit of G0461 for a PIN-4
IHC cocktail applied to one prostate biopsy specimen,
even though the report may give a result for each of the
three separately interpretable antibodies that make up the
primary cocktail stain (one vial).
According to the current work descriptor, one unit of G0461
can be billed for the first qualitative IHC stain for a given
tissue specimen. If you perform one qualitative IHC stain
on a specimen which then results into two, three or more
additional qualitative IHC stains from that specimen, each
such additional stain will be reported as one unit of G0462.
For example, if a single skin biopsy is worked up using
HMB-45, tyrosinase and Melan-A qualitative IHC stains
(three separate vials), youd report that as one unit of G0461
(first stain) and two units of G0462 (two additional stains).
Note: Codes G0641 indicates that it is intended for use
per specimen; first single OR multiplex stain.
On the other hand, with non-Medicare patients, pending
any restrictions from specific payors, providers should
continue using 88342 and the new add-on code 88343.
88342

Immunohistochemistry or immunocytochemistry,
each separately identifiable antibody per block,
cytologic preparation, or hematologic smear;
first separately identifiable antibody per slide.

+88343 each additional separately identifiable antibody

per slide

2014 AMA CPT Changes - Insiders View

Immunohistochemistry code 88342 has been revised
to more clearly define the unit of service. Prior to 2014,
88342 described Immunohistochemistry including
tissue immunoperodixase, each antibody. In 2014, the
code descriptor now includes immunocytochemistry
and describes each separately identifiable antibody per
block, cytologic preparation, or hematologic smear. The
unit of service is the first separately identifiable antibody
per slide. An add-on code (88343) has been added to
identify each additional separately identifiable antibody
per slide. When more than one antibody is applied to
the same slide, one unit of 88342 should be reported
and one unit of 88343 for each additional antibody. A
new parenthetical note following code 88343 provides
this instruction. The cross-reference parenthetical notes
following codes 88313 and 88319 have been revised to
include 88343.
Examples on billing for qualitative IHC stains, see the
Question and Answer (Q&A) section of this issue.
More information on billing for qualitative IHC stains can
be found at http://www.cap.org/apps/docs/advocacy/
ihc_education.pdf v

IHC Coding Examples

Q. You perform a biopsy by punch of an atypical
pigmented lesion, single specimen processed
into a single block A. An HMB-45 stain is
performed as well as a separate stained slide
using a Mib1-Mart1 antibody cocktail.
A. For commercial payers, you report:

(List separately in addition to code for primary
procedure)

HMB-45 (slide 1) and Mib1-Mart1 cocktail (slide 2)

88342 X 2
88343 X 1

Note: The 88342 code descriptor now states per block

which is a change from per specimen. Also note per
slide in reference to cocktails or multiplex IHC stains.
Thus, for non-Medicare patients, the only time one can use
88343 is with cocktails.

For Medicare, you report:

HMB-45 (slide 1) and Mib1-Mart1 cocktail (slide 2)

G0461 X 1
G0462 X 2

Note: MIB/Mart is sequential staining with 2 kits, so

each stain is billed separately.

For services rendered on or after the effective date, instead

of reporting 88342 X 3 for one block, you should now
report 88342, 88343 X 2.
Providers are reminded to note that the reporting sequencing of per specimen rather than per block applies to
Medicare, Tricare and Medicaid. Currently, Tricare and Medicaid agencies typically do not use HCPCS Level II codes.
However, CMS has not yet provided guidance on whether
one should use 88342 and 88343 or the G-codes with Tricare
and Medicaid claims. The American Academy of Dermatology and other affected societies have submitted an inquiry
for further clarification to CMS and will share the response
and outcome as soon as it is received. Providers are encouraged to reach out directly to commercial payers to ascertain
specific coding guidance that apply to each payer.
6

Derm Coding Consult: Summer 2014

Q. A large excisional specimen is received of a

previously biopsied dermatofibrosarcoma protuberans (DFSP) which due to the specimen size is
processed into a total of 10 separate tissue blocks.
During histologic evaluation it is determined that
the margins of the residual DFSP are indistinct
in 4 of the blocks and therefore a CD34 stain is
obtained on each of these 4 tissue blocks.
A. For commercial payers, you report:

88342 X 4

For Medicare, You report:

G0461 X 1
see IHC on page 7
CPT only 2013 American Medical Association. All Rights Reserved.

IHC Coding Examples

continued from page 6

Q. Punch biopsy of an atypical lymphoid infiltrate,

single specimen processed into a single block A.
CD4, CD8, CD20, and CD30 immunostaining are
performed on separate slides.
A. For Commercial Payer, you report:

88342 X4

For Medicare, you report:

Because you have four separately identifiable stains on

different slides (CD4, CD8, CD20 and CD30) from block
A it is appropriate to report each slide individually as
follows:

The report also compiled data by specialty, using the

primary specialty designated by each eligible professional
in the National Plan and Provider Enumeration System
(NPPES). In dermatology, 3,602 eligible professionals
earned an average PQRS incentive of over $1,500. These
successful participants represented about 31 percent of all
self-designated dermatology specialists eligible to participate in the program. Nearly 98 percent (1,667 of 1,708) of
those reporting via registry earned an incentive. Overall,
over 93 percent of dermatology professionals who participated in the 2012 PQRS program (through any means)
earned an incentive.
Total 2012 PQRS Participation and Success
Dermatology Compared with Other Specialties
Specialty

Number
participating

Number
earning
incentive

Percent
earning
incentive

Dermatology

3,853

3,602

93.5%

$887

$1,532

Plastic Surgery

1,006

878

87.3%

$233

$323

Urology

5,351

4,438

82.9%

$852

$962

Ophthalmology

11,135

9,216

82.8%

$1,304

$1,728

Psychiatry

3,989

3,562

89.3%

$63

$139

G0461 X1; G0462 X 3

Q. A biopsy by punch technique of an atypical nevus

on the back and another of the chest is performed.
A Melan-A stain is performed on both specimens.

For Commercial Payers, your report:

88342 X 2

For Medicare, you report:

G0461 X 2

Q. Excisional biopsy of an atypical nevus of the back

(one specimen processed into 3 tissue blocks, block
A1, A2, and A3). A melan-A stain is performed on
blocks A2 and A3.

For Commercial Payers, you report:

88342 X 2

For Medicare, you report:

Because a single Melan-A stain is performed on blocks

A2 and A3, which are from one specimen, it is only
appropriate to report G0461 x 1 v

2012 PQRS Reporting

Comparison for Dermatology
In March, the Centers for Medicare and Medicaid Services
(CMS) published its findings from the 2012 Physician Quality Reporting System (PQRS). Of the more than 435,000
participating eligible professionals in the PQRS program,
over 367,000 earned incentive payments totaling almost
$168 million. Individual eligible professionals earned an
average incentive amount of $457 and practices earned an
average of $5,736.
More PQRS participants earned incentives using the registry reporting option, with nearly 90 percent of eligible
professionals who reported with a registry earning incentives, compared to about 73 percent of participants who
earned incentives for reporting via claims.
CPT only 2013 American Medical Association. All Rights Reserved.

Median
Mean
incentive incentive
earned
earned

Source: 2012 reporting experience, including trends (20092013): Physician Quality Reporting System and electronic
prescribing (eRx) incentive program. March 14, 2014. v

(Correction to page 1,
Spring 2014 DCC)
Example:
Patient presents with 5 mm diameter ill-defined, suspicious mole with irregular margins on arm. Mole has varying
shades of color, though mostly pink with flat and bumpy
components.
Diagnosis: Dysplastic Nevus
ICD-10-CM Code: D232.60 Melanocytic Nevus of unspecified upper limb, including shoulder.
Versus:
Patient presents with 5 mm diameter ill-defined, suspicious mole with irregular margins on right upper arm. Mole
has varying shades of color, though mostly pink with flat
and bumpy components.
Diagnosis: Dysplastic Nevi
ICD-10-CM Code: D232.61 Melanocytic nevi of right upper
limb, including shoulder. v

Derm Coding Consult: Summer 2014

In The Know..
Some payers may not reimburse for closure by
intermediate repair when the defect size is less
than 1.0 cm.

For example, Aetna, under Other Payment Policies Services or supplies that have limited or no coverage
based on Aetnas Payment Policies, CPT 1203113160 Intermediate and Complex Repair: Aetna
does not allow separate payment for intermediate
or complex repairs with excision of benign lesions
that are 1.0 cm. or smaller. It is unlikely that this
type of repair would be done on lesions of this size.
However, if the operative report confirms that the
repair was actually performed on lesions of 1.0 cm
or smaller, an intermediate or complex repair will be
considered for payment.
In this policy, Aetna states that if the intermediate
closure was performed and has been documented,
providers can appeal the denial.

American Academy of Dermatology

PO Box 4014
Schaumburg, Illinois 60168-4014

According to coding guidelines and conventions,

repair by intermediate or complex closure should
be reported separately. For excision of benign
lesions requiring more than simple closure, ie,
requiring intermediate or complex closure, report
11400-11446 in addition to appropriate intermediate
(12031-12057).

Some payers may require documentation of how

many stitches were placed subcutaneously (state
specific location) as well as epidermal to show that
an intermediate repair was indeed performed.
Always check with the payer policy on reimbursement for intermediate repairs.
Now you are In The Know!

CPT only 2013 American Medical Association. All Rights Reserved.

Derm Coding Consult: Summer 2014