There are two codes for cerumen removal 69209 Removal impacted cerumen using irrigation/lavage, unilateral 69210 Removal impacted cerumen (separate procedure), 1 or both ears Key points Document the medical necessity for cerumen removal (patient’s complaints, diminished hearing, physical exam) Document the results: was the procedure successful? Whether it is a clinical staff member or practitioner […]
Removal of a Foreign Body
Integumentary 10120 Incision and removal of foreign body, subcutaneous tissues; simple 10121 Incision and removal of foreign body, subcutaneous tissues; complicated Note that incision is required. Musculoskeletal From Principles of CPT® Coding, “If fascia is penetrated and a foreign body to be removed is within the fascia, subfascia or muscle, use an anatomic-specific code in […]
Lesion Destruction Tip Sheet
CPT® does not make it easy to locate codes for destruction of lesion(s). These codes are found in multiple chapters throughout the CPT® book, and are classified by a variety of factors (size, method of destruction, type (pre-malignant/malignant/benign), etc.) Accurate coding is essential to accurate payment. This tip sheet was created to help you quickly locate the correct CPT® code for lesion destruction.
Commonly Performed Procedures in Primary Care | Reference Sheet
These reference sheets for minor procedures include common CPT® codes, descriptions, current work and non-facility RVUs, and global days for quick reference. The first chart includes codes 10060-11443, the second 11600-17111, and the third 20550-54056.
Can I Get Paid For…Removal of Sutures or Staples
In 2023, CPT® deleted code 15850 and revised code 15851. Prior to then, these codes differentiated between suture removal by the same surgeon who performed the primary procedure and suture removal performed by a different surgeon. It also used the term “under anesthesia other than local.” In CPT Changes 2023 An Insider’s View, the AMA said that […]
Coding for Mohs Micrographic Surgery
Mohs surgery is performed to remove complex or ill-defined skin cancer, and the procedure includes both the surgery and histopathologic examination. Both capacities are required in order to bill for these codes, and neither part may be delegated to another individual. Let’s look at the specific guidelines for coding for Mohs Micrographic Surgery: According to […]
Shaving of Epidermal or Dermal Lesions
The chart below includes CPT® codes, and descriptions for shaving epidermal and dermal lesions. After the chart, there are important key points to keep in mind when using these codes. Code Description 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 11301 lesion diameter […]
Coding for Destruction of Malignant Lesions
The primary factors in selecting a code for destruction of malignant lesions are: Selectd by size of lesion (not defect) Location Method is not a factor in code selection Report a code for each lesion treated Per Principles of CPT® Coding: “The destruction of malignant lesions is reported with codes 17260—17286. Similar to the codes […]
CPT® Codes for Fine Needle Aspiration
Fine needle aspiration biopsy Material is aspirated with a fine needle and the cells are examined cytologically. A core needle biopsy is performed with a larger bore needle to obtain a core sample. Use code 10021 for FNA without imaging guidance, first lesion and 10004 for each additional lesions. Use codes 10005 – 10012 for […]
Skin Biopsies
Correctly selecting and reporting skin biopsies requires an understanding of CPT® codes for skin biopsies There are codes for excision of benign and malignant lesions, and codes for shave procedures. Those are coded based on the size of the excision and location There are specific biopsy codes in other chapters, for biopsy of ears, lips, […]
Coding Guide – Minor Surgical Procedures
This guide includes definitions of minor procedures used frequently in primary care and urgent care. And, even more important, instructions for billing the services. No minor procedure guide would be complete without a discussion of modifier 25. It is also the reference for CodingIntel’s minor procedures webinar which you can watch here.
Selecting CPT® Rules for Excision of Skin Lesions
Many medical practices perform skin procedures. A patient may see a dermatologist, a family physician or a surgeon when the time comes to find out, “What’s this thing growing on my arm?” This article discusses excision of benign and malignant lesions. Shaves, biopsies, and destruction of lesions are covered in other articles. Per CPT, excision […]
Destruction of Benign or Pre-Malignant Lesions
Finding the right code for lesion destruction is not easy. The codes are distributed in the CPT® book in the integumentary, digestive, male genital system, female genital system, and eye and ocular systems. Some of the codes are selected by the method of destruction and some are not. Some of the codes are selected based […]
Billing for Multiple Surgical Procedures
When billing for multiple procedures on the same day, use this step by step procedure to determine if you should bill for more than one procedure, and if so, if you should use modifier 51 or modifier 59. It is critical to have access to National Correct Coding Initiative ((NCCI) edits in your software program. […]
Excision of Benign or Malignant Lesions
This article reviews codes and guidelines for excision of skin lesions. For more information about minor procedures, see additional resources at the bottom of this page. This article includes: CPT® Codes for Excision Excision of Benign Lesions Excision of Malignant Lesions Excision of Soft Tumors Reporting Excision of Multiple Lesions of the Same Size Coding […]