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Introduction
CHAPTER 10 Billing and Financial
Considerations in Dermatologic Surgery
Alexander Miller Ann F. Haas
SUMMARY
The goal of complete and accurate coding is to clearly define to a payer what
was performed during a given patient care interaction.
Each procedural charge submitted to a payer must be correlated with a valid
diagnostic code.
Beginner Pearls
Determine the excision code size by adding the maximum lesion diameter to that of the
summed narrowest bilateral excision margins.
If a patient evaluation leads to a 90-day global procedure done on the same day, then
the evaluation and management service is separately billable with modifier .57 appended.
Expert Pearls
Immunohistochemical stain coding is defined as per specimen, and not per block of
tissue.
Redundant tissue removal (standing cones or dog ears) does not elevate an otherwise
linear closure procedure to the level of a flap, though it may turn an otherwise intermediate into a complex linear repair.
When a defect or a portion of a defect is repaired with a Burowโs graft generated from
a linear excision and closure adjoining the defect, only the skin graft procedure is billable, as the graft code includes the excision and direct closure of the donor defect. Mohs surgery is still billable separately, though it may be subject to the multiple procedure reduction rule.
Donโt Forget!
When more than one repair of the same type (simple, intermediate, or complex) is
done within one anatomical area, sum the lengths of the repairs and bill for one closure, as directed by the site and sum of the of the repair lengths. If repairs of the same type are done in different anatomical code group areas, then bill each one individually.
A Z-plasty generated from the edge of a flap to promote the flapโs mobility does not
constitute an additional separate flap.
Pitfalls and Cautions
Avoid using โunspecifiedโ (NOSโNot Otherwise Specified) diagnostic codes,
highlighted in yellow in the ICD-10 manual, as this indicates that the medical record lacked sufficient information for a more precise code selection. Some insurers may deny claims with โunspecifiedโ codes.
Excisions of epidermal inclusion and pilar cysts that extend into the subcutaneous
space should be coded with the integumentary excision codes, as these entities are of skin, and not subcutaneous, origin.
Patient Education Points
It is worth explaining to patients that physicians will bill insurance companies as a
courtesy to them, but that ultimately it is the patientโs responsibility to cover the cost
of any procedures performed.
Explaining that the surgeon is bound by the terms of a contract with the insurer helps
the patient understand that the surgeon is indeed their ally.
CHAPTER 10 Billing and Financial