Surviving Financially

Published on 04/03/2015 by admin

Last modified 22/04/2025

Print this page

This article have been viewed 1968 times

38 Surviving Financially

John L. Pfenninger, MD, and Rebecca Small, MD

One important way to survive financially is to be paid appropriately for the procedures performed in the office. Coding and billing for skin procedures can be very complex. It is essential for the practitioner to understand the idiosyncrasies of the ICD-9 and CPT codes if billing is to be completed correctly.¹^–⁷ The objective is not to charge as much as possible, but rather, to optimize billing once the proper procedure has been performed. Oftentimes, the same procedure can be billed using three or four different codes. Without exception, one method will pay more. Knowing the proper application of billing rules can, and does, make a significant difference in the financial bottom line of the practice.

Aesthetic procedures are not reimbursed by insurance carriers and, thus, there are no formal “rules” or “regulations” regarding the fees charged. The inclusion of these procedures has the potential to significantly augment practice revenue. Start-up costs for aesthetic procedures vary widely from relatively inexpensive products for chemical peels, to moderately expensive injectable products such as botulinum toxin and dermal fillers, to more expensive equipment such as aesthetic lasers.

Procedures have in the past and currently do reimburse more than cognitive visits on a time comparison basis. The primary care physician frequently turns away the most financially rewarding parts of the practice when sending patients for consultation. Many dermatologic procedures are easily learned, take little time to perform, and are appreciated by the patient since they do not have to arrange for a consult with another physician. These procedures often provide immediate or quick feedback to the clinician and patient about the diagnosis.

Unless a clinician is going to enter into the aesthetic field, the instruments used to perform dermatologic procedures are inexpensive. The most costly would be an electrosurgical unit and a liquid nitrogen gun (see Chapters 14 and 15). On the other hand, aesthetic equipment such as lasers can be very expensive, exceeding $150,000. However, when properly utilized on a frequent basis, lasers will offer the greatest revenue returns compared to other aesthetic procedures that require consumable products, such as botulinum toxin and dermal fillers. Cost versus fee charged for aesthetic laser treatments is more difficult to analyze due to the multiple variables involved such as methodology of acquiring the capital equipment, incidental disposable goods, cost of office space for storing the device, and maintenance contracts ($10,000 per year is common for aesthetic lasers).

A properly designed spreadsheet can be used to estimate whether major investments will provide an adequate financial return. Sales representatives will often paint a rosy picture and provide flow sheets which always conclude that there will be a significant return on investment. Major investments, however, require a careful independent study analysis of main factors.⁸

The purpose of this chapter is to help the reader become familiar with proper CPT coding for biopsies, destructions, and excisions of skin lesions. It will also help identify the pitfalls and common errors in coding and discuss financial considerations for aesthetic procedures. Tables 38-1 and 38-2 list common coding terminology and modifiers.

TABLE 38-1 Coding Terminology

Ablation	See “Destruction”
Balance billing	The process of charging a patient the difference between what the physician bills and what the insurance company pays. If a provider participates with an insurance carrier, only copays and deductibles may be charged to the patient. If there is no participation agreement, then the provider may bill the patient for any fees not paid by the insurance company.
Biopsy	The procedure used to obtain tissue for histologic examination. This can be done with shave, punch, excision, curettement, and incisional procedures.
Electrosurgery/fulgurate/desiccate/cauterize	The use of electrical current heat to treat/destroy an area.
CPT	Current Procedural Terminology, published and updated annually by the AMA. Every medical procedure has a CPT code number. The majority of billing is completed using CPT terminology.²
Cryosurgery	The use of low temperatures to destroy (by freezing) a lesion (liquid nitrogen; nitrous oxide closed system; chemical spray canisters).
Debridement	Removal of devitalized tissue, dirt, and/or eschar from wounds or infected areas.
Destruction	Treatment of a lesion using cryosurgery, chemical application, injection of a chemical, curettement, or electrosurgery. Using a shave technique would also qualify, but in general, reimbursement would be higher using a shave or biopsy code than a destruction code for benign lesions.
Explanation of benefits (EOB)	A sheet provided by insurance companies that is enclosed with the payments for various procedures explaining what is allowed, what is the patient’s responsibility (copay, deductible, not covered), what is not allowed (must be “written off” by the provider), and the amount of the enclosed payment.
Excision	Removal of a lesion using sharp dissection or electrosurgical cutting. In a shave excision, a slicing technique is used to remove either all or a portion of the lesion. It does not require suturing. Elliptical or fusiform excision includes full-thickness (through the dermis) removal of the lesion and requires closure, usually with sutures (or glue or adhesive strips).
Global period	Certain procedures have global periods. During this time, additional services (relating to the original procedure) cannot be charged. For most skin surgical procedures, this period is 10 days (no global period for shaves and punches).
ICD-9 (International Classification of Diseases, 9th Revision)	Every diagnosis has a specific numbered code. A diagnostic code is required to justify the reason for a CPT (procedure) code.¹ The ICD-10 codes are currently scheduled to be implemented October 1, 2013.
Incision and drainage (I&D)	Simple: Contents expressed after incision.
Incision and drainage (I&D)	Complex: Multiple conditions would qualify for a complex I&D, including the removal of a sac, such as in a sebaceous cyst, or insertion of a drain, such as iodoform gauze. The size and depth of the abscess could also be a factor, as well as excessive time required to complete the procedure. If multiple I&Ds of different lesions are done at the same time, it would also be considered “complex.”
J-codes	Nearly every injectable medication has a specific number assigned to it called the J-code. When administered, the physician charges for not only the administration itself (a CPT code), but also for the particular chemical delivered (identified by the J-code).
Modifiers	These are numbers appended to a CPT code while billing to indicate that more than just the usual services were provided for the particular CPT code. (See Table 38-2 for common modifiers).
Paring	Removal and/or decrease in the bulk of a lesion, by peeling or shaving it away using a scalpel or a sharp instrument.

TABLE 38-2 Common Modifiers

-25	Significantly separate E&M on the same day as a procedure.
	Example: If a patient comes in for a mole removal and you have documentation that you also treated the patient for hypertension, osteoporosis, smoking, etc., use the -25 modifier with the office visit code.
-50	Bilateral procedures.
	Example: If you perform sclerotherapy on both legs, you would use the -50 modifier with the sclerotherapy code.
-51	Multiple procedures.
	Example: When multiple procedures, other than E&M, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier -51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes.
-59	Distinct procedural service.
	Example: If you performed a cyst excision and decided to also freeze some actinic keratoses, use the -59 modifier with the cryosurgery because it is a completely separate procedure from the excision.
-79	Unrelated procedure or service by the same physician during a postop period.
	Example: If a patient comes in to have sutures removed during the postop period, and you perform cryosurgery on some actinic keratoses at the same visit when the sutures are removed, then -79 is used to clarify a separate procedure during a postop period.

Essentials for Proper Coding and Billing

To code and bill properly, the following information is necessary:

• Size of the lesion (if appropriate)

• Location on the body

• Method of treatment

• ICD-9 diagnosis (especially important to designate whether it is benign or malignant)

• CPT code.

Although most practitioners do not perform their own billing, it is increasingly more common for clinicians to complete their own coding. Accurate documentation and coding (including the location, size of a lesion, whether it was benign or malignant) will lead to accurate billing.

ICD-9 Coding

The majority of dermatologic procedures will involve an abnormal lesion. The diagnostic code (ICD-9) will vary depending on the location on the body and whether it is malignant (primary, secondary, or carcinoma in situ), benign, of uncertain behavior, or unspecified behavior (see Table 38-3). Specific conditions will have separate codes: abscesses, foreign bodies, cysts, etc.

TABLE 38-3 Neoplasm, Skin-ICD-9CM Codes

When the diagnosis is uncertain, several options are available. One can use the “uncertain behavior” code if the procedure is a biopsy. If a definitive treatment is performed, it sometimes helps to wait for the pathology to return before completing the billing process. It is best not to use the “unspecified” code because, for whatever reason, many insurance plans will reject that code. If a biopsy was performed, the reimbursement will be the same whether it is coded as “benign” or “malignant.” It makes little difference if the code is correct when only a biopsy was done. However, it is extremely important to know if the lesion was benign or malignant if a treatment is carried out. Note the differences in Table 38-4 for the 50th percentile charges and reimbursement for benign and malignant lesions. These lesions could have been treated with liquid nitrogen cryosurgery, electrosurgery, laser ablation, or other methods. The same time may have been required whether the lesion was benign or malignant, but the fees charged and eventually reimbursed vary markedly.

TABLE 38-4 50th Percentile Charges (National) for Destruction of Selected Skin Lesions and the Average Medicare Reimbursement (2010)

A clinician can code for specific entities or be more generic. For instance, if a patient had a malignant melanoma on the back, it could be coded out specifically for “melanoma, general” as 172.9. It could also be coded out generically as “malignant neoplasm of the back,” 173.5, which also includes squamous cell, basal cell, and other skin neoplasms. As long as it is a malignant code, it will not change the billing. A seborrheic keratosis on the face could be coded very specifically as 702.19 or more generally as 216.3 (benign lesion, face). Unfortunately, billing for treatment of benign lesions including seborrheic keratosis (regardless of the code) may be denied as it is often considered cosmetic. However, if a seborrheic keratosis is inflamed (ICD-9 702.11), most insurance companies will reimburse for its destruction or excision.

There is no specific code for premalignant lesions, such as actinic keratoses, on a particular body part. They can all be coded as 702.0 (actinic keratosis), regardless of location. However, reimbursement is higher for destruction of multiple premalignant lesions because each lesion (e.g., actinic keratosis) is charged individually (see Table 38-5).

TABLE 38-5 Destruction of Benign and Premalignant Lesions

The Importance of Size

Lesion size can be a major determinant in reimbursement. For some codes such as destruction for benign or premalignant lesions, size does not make a difference. However, if the lesion is malignant, the reimbursement varies widely (see Table 38-4). Similarly, size is very important in the repair of lacerations. For all excisions, size is best determined prior to the injection of any anesthetic.

The Importance of Location

It is critical to know that the same procedure performed on different anatomic locations is reimbursed differently. Even for benign destructions, where size and location usually does not matter, there are some exceptions. For instance, treatment of benign lesions of the penis, vulva, vagina, perineum, anus, and the eyelids all have distinct CPT codes (see Table 38-6). Biopsy codes are also specific for similar sensitive areas (see Table 38-7).

TABLE 38-6 Selected Benign Skin Destructions

TABLE 38-7 Biopsy by Punch, Shave, Curette, or Excision

CPT codes and reimbursement numbers are provided in Table 38-8 for incision and drainage (I&D) procedures and in Table 38-9 for foreign body removal.

TABLE 38-8 I&D Procedures

TABLE 38-9 Foreign Body Removal

The Importance of Method

In general, the method of destruction does not change the coding. However, for the anus and genital areas, there are specific codes for the method used (see Table 38-6).

Shave excisions are distinctly different than full excisional procedures that require suture repair. Here, again, the “method” is important. Specific codes are used for shave excisions depending on size and location (see Table 38-10).

TABLE 38-10 Selected Shave Skin Excisions

Specific CPT Codes: Office Visits

An E/M code can be charged in addition to a procedural code in specific, certain instances:

• If the patient is new to the practice or has not been seen by the practice for at least 3 years, a new patient visit E/M can be charged. It is felt that it is necessary to evaluate the patient’s overall condition in addition to providing the procedure itself. Does this patient have diabetes? Is he or she on warfarin? Have other mitigating diagnoses? It takes time to determine this and the clinician is reimbursed for that time.

• If the patient has been seen in the practice within 3 years but a unique, separate service is provided in addition to the procedure, use the modifier “-25” and charge for the office visit E/M. Perhaps the patient’s insulin or hypertensive medications were adjusted, or a URI may have been evaluated in addition to doing a skin biopsy on the face for a suspected basal cell carcinoma.

• If the patient is being seen as a consult, a consult fee can be charged in addition to the procedure fee. Although Medicare eliminated this consultation fee in 2010 and some insurance companies have followed suit, other insurance companies still follow the CPT uniform coding guidelines, which allow the additional E&M code. It is important to know which insurance companies allow this because it can generate a significant cash flow in some practices.

Intralesional Injections

Injection therapy may be used when treating acne, keloids, or other skin conditions with steroids. Also, injecting Candida antigen or bleomycin for the treatment of verruca qualifies for intralesional injection codes. The coding is as follows: 1–7 lesions is 11900; >7 lesions is 11901. Note that the number refers to the number of lesions, not the number of injections. For some conditions such as verruca, one could also use destruction codes. For most drugs, an additional charge is made for the medication itself, using a J-code, and the amount of solution used.

I&D Codes

A simple incision and drainage is billed with CPT code 10060; for complex or multiple lesions, the code is 10061. However, note that many locations have specific CPT codes (see Table 38-8). Those particular codes should be used rather than the generic ones since they often reimburse more.

Biopsies

The CPT code for a biopsy is method independent. In other words, shave, curettement, punch, incision, or excision could all be coded as a biopsy. If the biopsy codes are used, it does not really matter if the lesion is benign or malignant nor does the size matter, but location will make a difference. For most locations on the body, the first biopsy is coded as 11100 and there is a charge for each additional biopsy done (code 11101). Note that many of the specific biopsy CPT codes are dependent on the particular site biopsied (see Table 38-7). If a complete full-depth excision with a sutured repair is performed, it will most likely be compensated at a higher rate if billed as an excision and not as a biopsy (even when the diagnosis is not certain and the specimen is sent to pathology). For example, if an excision of a suspected BCC with margins is performed at the first visit, the reimbursement would be much higher for excision of a malignancy than biopsy of an unknown lesion.

Excisions and Lacerations

Coding for excisions can be straightforward. All of the previously identified factors need to be recorded: benign or malignant, location, and size. All measurements should be made before any anesthetic is administered. For the purpose of billing, the size of the lesion is determined by the “greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)” (see Figure 38-1). If a lesion is long and narrow, the length plus the margins is actually the “diameter” size used for coding. So, in essence, it is the largest measurement of the lesion plus the margins that is used for proper coding:

A:Correct size for coding is “excision of 3-cm lesion, malignant, back,” with the actual size of the lesion itself being 1 cm × 1 cm with 1-cm margins around it (1-cm margin + 1-cm lesion + 1-cm margin).

B:Correct size for coding is “excision of 2.4-cm lesion, benign, neck,” with the actual size of the lesion itself being 2.0 cm long × 1 cm wide, with 0.2-cm margins around it (0.2-cm margin + 2-cm lesion + 0.2-cm margin).

C:Correct size for coding is “excision of 1.9-cm lesion, malignant, nose,” with the actual size of lesion itself being 0.8 cm wide × 0.9 cm long, with 0.5-cm margins around it (0.5-cm margin + 0.9-cm lesion + 0.5-cm margin). To make it clear, “diameter” size refers to the longest measurement of the lesion.

FIGURE 38-1 Measuring and coding the removal of a lesion.

(Adapted from Physicians Current Procedural Terminology 2010. Chicago: American Medical Association; 2010.)

For excisions, the code includes the surgical supplies, administration of local anesthesia, a simple repair, suture removal, and any necessary intervention within 10 days. This 10-day period is called the global period.

In the repair of lacerations there is no “width” determinant. Rather, it is only the length of the laceration to be repaired that is important (simple repair). Some laceration repairs will be considered intermediate or complex based on factors described below. In these cases, the length will still be one of the factors used in determining the correct CPT code.

Intermediate and Complex Repairs

A repair can be classified as intermediate or complex as follows:

• An intermediate repair (12031–12057) is defined by the CPT manual as a repair that includes, in addition to the requirements of a simple repair, “… layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.” Intermediate repair includes either extensive cleaning, debridement, undermining, or placement of deep buried sutures. Intermediate repair increases the amount of charges significantly. Do not forget to bill for this portion if your repair is truly an intermediate one. See Table 38-11 for codes, descriptions, and Medicare pricing.

• A complex repair (13100–13160) is defined by the CPT manual as a repair that “includes wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Necessary preparation includes creation of a defect for repairs (e.g., excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions.”

TABLE 38-11 CPT Codes for Intermediate Wound Repair

CPT	Description	2010 Medicare National Nonfacility Price
12031	Scalp, axillae, trunk and/or extremities (excluding hands and feet), <2.6 cm	$226
12032	2.6–7.5 cm	$287
12034	7.6–12.5 cm	$286
12035	12.6–20.0 cm	$347
12041	Neck, hands, feet and/or external genitalia, <2.6 cm	$236
12042	2.6–7.5 cm	$272
12044	7.6–12.5 cm	$318
12045	12.6–20.0 cm	$348
12051	Face, ears, eyelids, nose, lips and/or mucous membranes, <2.6 cm	$251
12052	2.6–5.0 cm	$287
12053	5.1 cm–7.5 cm	$316
12054	7.6 cm–12.5 cm	$335
12055	12.6 cm–20.0 cm	$402

If an intermediate or complex repair is performed, that can be billed in addition to the excision itself. An intermediate repair after an excision generally includes undermining and the placement of sutures to close the deep space (layered closure).

Even the use of a single deep suture allows one to bill for an intermediate repair. The compensation for such a repair may be comparable to the compensation for the excision itself. Therefore using deep sutures when needed not only protects the patient from risks of dehiscence and hematoma, it also increases the reimbursement. When coding for intermediate repair after an excision it may help to include the reason for the deep sutures in the operative note. The most common reasons are to “take tension off the wound,” “prevent dehiscence,” or “close dead space.”

The CPT code for an intermediate repair is based on the length of the final closed wound (regardless of the size of a lesion or the mechanism of an injury). The codes for intermediate repairs encompass wide ranges of wound length as these are also used for laceration repairs (see Table 38-11). When it comes to laceration and wound repairs that are unrelated to a medical excision, intermediate repairs are billed instead of a simple repair and not in addition to the simple repair. Reasons to upgrade a simple repair to a complex repair beyond just a two-layer closure include the need for extensive wound cleaning and/or debridement before closure.

A complex repair can be billed if extensive undermining or debridement is required or if the time required for the procedure is excessive. If a flap, plasty, or graft is performed, other specific codes (14000 and 15000) apply. See Chapter 13 for further information on billing for flaps.

Destruction of Lesions

The number one determinant for the correct CPT code for a lesion destruction is whether the lesion is benign, premalignant, or malignant. If benign, destruction by any method of 1–14 lesions is the same code: 17110. If 15 or more are destroyed, then the code is 17111. The exceptions for various locations are noted in Table 38-6. If premalignant (e.g., actinic keratoses), the first lesion is coded as 17000. For lesions 2–14, 17003 is used, and a charge is made for each additional lesion. Use 17004 when 15 or more premalignant lesions are treated.

For malignant lesions, size becomes important as well as location (see Table 38-12).

TABLE 38-12 Malignant Skin Destructions

Tumors

The removal of subcutaneous tumors, such as lipomas, carries a specific diagnosis. These are not skin lesions. The CPT code was changed in 2010 and the proper code is determined based on whether the lesion is subcutaneous, subfascial, or whether it requires a radical excision. It does not matter if it is benign or malignant, but body site and depth of lesion do change the CPT code (Tables 38-13 and 38-14).

TABLE 38-13 Subcutaneous Soft Tissue Tumor Excisions above the Fascia (Used for Lipomas)

TABLE 38-14 Soft Tissue Excision Codes

These codes are all inclusive. Neither the length of the incision nor the type of repair that is used matter. The size of the tumor is determined by the maximum dimension of the tumor plus the narrowest margin necessary to excise the tumor completely. Subcutaneous is defined as “below the skin but above the deep fascia.” Fascial or subfascial is defined as “within or below the deep fascia, but not involving the bone.” In the fingers and toes, however, subfascial is defined as “involving the tendons, tendon sheaths, or joints.” Tumors that “abut but do not breach the tendon, tendon sheath, or joint capsule are considered subcutaneous.”

All subcutaneous tumors are reported by whether they are <3 cm or ≥3 cm, except:

• Face/scalp: <2 cm or ≥2 cm

• Hand/finger: <1.5 cm or ≥1.5 cm

• Foot/toe: <1.5 cm or ≥1.5 cm.

All subfascial tumors are reported by whether they are <5 cm or ≥5 cm, except:

• Face/scalp: <2 cm or ≥2 cm

• Forearm/wrist: <3 cm or ≥3 cm

• Hand/finger: <1.5 cm or ≥1.5 cm

• Foot/toe: <1.5 cm or ≥1.5 cm.

Also, the routine skin diagnostic ICD-9 codes are not used. Rather, ICD-9 provides specific codes for subcutaneous and deep tumors of the various body locations (see Table 38-15). It is important to be aware of these tumor removal codes, because the majority are much more highly reimbursed than those for skin lesion removal. A small subcutaneous 1-cm lipoma on the back that is removed with a simple incision and digital expression with a Steri-Strip closure (CPT 21555) can take a mere 5 to 10 minutes. The 50th percentile fee charged is $805. Medicare reimburses $205. For a more detailed discussion of lipoma coding see Chapter 12, Cysts and Lipomas, page 145.

Miscellaneous

• When a malignant lesion is removed and the margins are positive, or further removal is recommended, even if the second tissue histology comes back totally benign or without residual, it is correct to charge for “malignant removal” for the second excision.

• It is inappropriate to use a biopsy and a removal code for the same visit.

• As is very evident from these discussions, proper coding and billing are complicated processes and Medicare reimbursement lags far behind the 50th percentile fees charged in the nation.

TABLE 38-15 ICD-9 Codes for Soft Tissue Tumors

CPT	Description
Benign Soft Tissue Tumors
(Do not use “Neoplasm–Skin” codes. These CPT codes are for deep soft tissue masses with their own distinct specific codes, both benign and malignant.)
210.4	Benign neoplasm, gum
214.0	Lipoma, face, SQ
214.1	Lipoma, other SQ tissue
215.0	Benign neoplasm, face
215.0	Benign neoplasm, neck
215.0	Benign neoplasm, head
215.2	Benign neoplasm, shoulder
215.2	Benign neoplasm, upper extremity
215.3	Benign neoplasm, hip
215.3	Benign neoplasm, lower limb
215.4	Benign neoplasm, thorax
215.5	Benign neoplasm, abd. wall
215.6	Benign neoplasm, buttock
215.7	Benign
215.7	Benign neoplasm, trunk
229.8	Benign neoplasm, hand
Malignant Soft Tissue Tumors
171.0	Cancer, head
171.0	Cancer, face
171.0	Cancer, neck
171.2	Cancer, upper limb
171.2	Cancer, shoulder
171.3	Cancer, hip
171.3	Cancer, lower limb
171.5	Cancer, abdominal wall
171.7	Cancer, back/flank

Prior Approval

Review the denials of payment for procedures monthly. It is not unusual for insurance plans to require prior approval for the most expensive procedures. These often involve excision of a malignancy and/or an intermediate repair. This can be an advantage of doing a small biopsy first to determine the diagnosis. Once a malignant skin lesion is diagnosed, complete a prior approval form for excision or other treatment planned. However, if the lesion is clinically an obvious malignancy, performing a biopsy only adds unnecessary cost. Insurance will allow approvals based on good clinical judgment. Approval is best done at the time when the patient is first seen and scheduled for definitive treatment. Allow time for the insurance company to respond if possible before performing the procedure. If prior approval is not received first, the insurance company may deny reimbursement, which can be a costly loss.

Once a clinician learns which insurance plans require prior approval for which procedures, fewer denials of claims will occur.

Cosmetic Versus Medical Removals

There are no codes for purely cosmetic removals. Some cosmetic treatments may be used for medical conditions and some insurance plans will pay for them (e.g., microdermabrasion or skin peel for acne and acne scarring). When the treatment is performed for purely cosmetic reasons or if the insurance plan does not cover a particular code, the practitioner is free to charge whatever is desired and no CPT coding or diagnostic code is needed.

Medicare coverage for lesion removal is quite strict. If a lesion is benign, they will pay for the removal only if it has one or more of the following characteristics: It is bleeding; it causes intense itching or pain; or the lesion has physical evidence of inflammation with purulence, oozing, edema, or erythema. It will also pay if it obstructs an orifice or clinically restricts vision, there is uncertainty as to the diagnosis, a prior biopsy suggests malignancy, or if it is in an area subject to recurrent trauma and there is documentation that such trauma has occurred.

Benign skin lesion removals (not including premalignant lesions) for reasons other than those provided above are considered to be cosmetic by Medicare. These include, but are not limited to, emotional distress, makeup trapping, and any nonproblematic lesion in any anatomic location. For patients with Medicare, if the procedure is deemed to be a cosmetic removal, the patient must be informed beforehand and sign a written consent that he or she understands and is willing to pay for the procedure. It is best to provide a specific written quote amount to all patients for these elective procedures. Interestingly, insurance companies will still cover pathology charges for lesions that were removed for cosmetic reasons.

Cosmetic procedure codes (Box 38-1) are primarily used for documentation purposes, because these procedures are not usually covered by insurance plans. As mentioned, some insurance carriers may cover chemical peels for conditions such as acne, but such coverage is not common. The 17000 code may be used for cosmetic laser treatments.