INSURANCE ISSUES: SKIN LESIONS: RECOMMENDED CRITERIA FOR THIRD-PARTY PAYER COVERAGE
The American Society of Plastic Surgeons (ASPS) is the
largest organization of plastic surgeons in the world. Requirements for
membership include certification by the American Board of Plastic Surgery as
recognized by the American Board of Medical Specialties.
ASPS represents 97 percent of the board-certified plastic surgeons practicing
in the United States and Canada. It serves as the primary educational resource
for plastic surgeons and as their voice on socioeconomic issues. ASPS is
recognized by the American Medical Association (AMA), the American College of
Surgeons (ACS) and other organizations of specialty societies.
A skin lesion is any alteration in the normal skin
architecture. Lesions can be benign, malignant or pre-malignant. Although a
comprehensive listing of skin lesions is beyond the scope of this paper, some of
the more common lesions will be mentioned in this section.
Benign skin lesions are common and include warts, cysts, moles, dysplastic
nevi, skin tags, lipomas, granulomas, keratoacanthomas, hypertrophic scars, and
keloids and are favorable for recovery. ICD-9 Codes that apply: 078.0-078.19,
214.0-214.9, 216.0-216.9, 228.0-228.1, 232.1-232.7, 238.2, 448.1, 528.5, 690,
691.8, 692.70, 695.89, 701.0, 701.2, 706.2.
A pre-malignant lesion, given time, may become malignant. Examples of
pre-malignant lesions include dysplastic nevi, giant congenital nevi, nevus
sebaceous, actinic keratosis and Bowen's disease. ICD-9 Codes that apply:
232.0-232.7, 238.2, 702.0.
A malignant skin lesion is a lesion that is becoming progressively worse and
can do great harm. It is liable to metastasize. The most common malignant
lesions are basal cell carcinomas, squamous cell carcinomas and melanomas.
Almost always the treatment of choice is complete excision that includes a
variable margin of surrounding tissue in order to eradicate microscopic tumor
cells that may have spread beyond the visible borders of the lesions. ICD-9
Codes that apply: 172.0-172.9, 173.0-173.9, V10.82, V10.83.
Unfortunately, it is not always possible to clinically differentiate a skin
lesion into one of these categories; thus any lesion that is suspicious for
malignancy or clinically problematic may require biopsy or excision.
Cosmetic and Reconstructive Surgery
For reference, the following
definition of cosmetic and reconstructive surgery was adopted by the American
Medical Association, June 1989:
Reconstructive surgery is performed on abnormal structures of the body,
caused by congenital defects, developmental abnormalities, trauma, infection,
tumors or disease. It is generally performed to improve function but may also be
done to approximate a normal appearance.
Cosmetic surgery is performed to reshape normal structures of the body in
order to improve the patient's appearance and self-esteem.
Removal of a Skin Lesion
The removal of a skin lesion can range from
simple to radical excision, and the resultant defect may be simply closed or
require reconstructive techniques of varying complexity involving skin grafts,
flaps or tissue transferred by standard or microvascular means.
A. In certain cases, lesions may be removed through shaving
(CPT codes 11300-11313), or destruction by any other method including laser (CPT
codes 17000-17002, 17100-17104, 17110). The appropriate procedure codes for the
simple excision and closure of benign skin lesions are CPT codes 11400 - 11446.
B. Excisions of malignant lesions using simple excision and closure are coded
11600 - 11646. In the case of melanomas and some unusual skin tumors, radical
resection of the tumor may be required; the procedure can be coded with any of
these CPT codes: 21015, 21557, 21935, 23077, 24077, 25077, 26117, 27049, 27329,
C. The repair of the defects that have been created may require intermediate
layered closure, complex closure or adjacent tissue transfer or re-arrangement.
If the wound is closed with any of these repairs, coding is necessary for only
the repairs as lesion removal is included in the codes for these repairs. Repair
codes that may be used include 12031-12057, 13100-13152, 14000-14061.
The skin graft codes (15050 - 15261), tissue expansion (11960, 11971) and
flap codes (15570 - 15740, 15755, 15760) may be indicated at times.
Indications for removal of skin lesions fall into one
of three categories:
1. The patient desires to have a skin lesion removed
solely because of appearance. This is considered cosmetic.
2. The lesion is malignant or pre-malignant (i.e. dysplastic nevi, giant
congenital nevi, nevus sebaceous and Bowen's disease). Depending on the size and
type of tumor, a variable margin of surrounding tissue is removed to eradicate
microscopic tumor cells that may have spread beyond the visible borders of the
lesion. The biopsy can either be incisional (in which a small portion of the
most suspicious area is removed) or excisional (the entire lesion is removed for
histological examination). Once a lesion is removed, closure of the wound may
require a simple repair or a more complex reconstructive procedure as outlined
3. The lesion is benign but is either rapidly enlarging, obstructing an
orifice (e.g., mouth, nose, ear etc.), restricting vision, chronically irritated
with evidence of inflammation (e.g., purulence, oozing, edema, erythema, etc.),
bleeding, prone to infection, intensely itchy, or affected by pressure. Some
skin lesions, such as warts, skin tags, trichoepithellomas, etc. have a very low
probability of malignancy but may be in areas where chronic irritation may occur
as a result of repeated, documented trauma, such as neck, axilla, bra line,
waist or groin. Such lesions are removed to eliminate irritation that might lead
to a more chronic problem or conversion to skin cancer. When there is clinical
uncertainty to the diagnosis, especially when there is a previous history of
skin cancer, biopsy or excision of the lesion is medically indicated. Depending
upon the size, location and appearance of the lesion, a biopsy can be either
incisional or excisional. Once removal of a lesion has occurred, closure of the
wound may require a simple repair or a complex reconstructive procedure.
It is the position of the American Society of
Plastic Surgeons that excision of malignant skin lesions and pre-malignant skin
lesions and procedures required to repair the defect created by excision are
medically indicated and should be compensable by third-party payers.
It is the position of the American Society of Plastic and Reconstrucitve
Surgeons that if the clinical diagnosis is uncertain, especially if there is a
history of skin cancer, biopsy or excision of the lesion is medically indicated
and should be compensable by third-party payers. This includes lesions that are
rapidly enlarging, obstructing an orifice, restricting vision, chronically
irritated with evidence of inflammation, bleeding, are prone to infection,
intensely itchy, or affected by pressure. Removal of skin lesions with a low
probability of malignancy that are repeatedly traumatized or present in areas of
chronic irritation should be removed to eliminate irritation that could lead to
a more chronic problem or conversion to skin cancer. Removal of such lesions and
procedures required to repair the defect created by the excision are medically
indicated and compensable by third-party payers. If a lesion that is removed for
cosmetic reasons shows malignancy or pre-malignancy on pathologic exam, the
procedure is medically necessary and should be compensable by third-party
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