1. Correctly Distinguish Closure Levels Every
Time With This Advice
Follow our tips to dig deeper and find the differences.
All closures aren’t created equal; one of the nuances of coding these procedures is
knowing how to distinguish one type from another. Read on for our experts’ advice on
how to assess the three closure levels and assign the best codes.
Remember ‘Simple’ Doesn’t Mean ‘Easy’
A simple repair involves primarily the dermis and epidermis. It might involve
subcutaneous tissues, but not deep layers.
Draw the line: How do you know when a closure might involve subcutaneous
layers but is still considered a simple repair? Your provider’s documentation is the key.
“The difference is whether the wound is closed in layers or just a single layer,” says
Kevin Arnold, BHA, CPC, business manager for the Emergency Medicine Department
at Norwalk Hospital in Norwalk, Conn. “The provider might decide to include the
subcutaneous layer in the closure but does so by bringing the needle through the dermis
into the subcutaneous and back. That results in a single-layer closure rather than
closing the subcutaneous layer first and then the dermis/epidermis second in separate
closure techniques.”
But “simple” doesn't mean the repair is something anyone could do. Simple repairs
involve one-layer closure, which helps set them apart from a standard E/M procedure.
For example, if your dermatologist uses adhesive strips to close a laceration,
consider it an E/M service that you’ll report with the best-fitting choice from codes
99201-99205 (Office or other outpatient visit for the evaluation and management of a
new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and
management of an established patient …).
“Most steri-strip applications are done by nursing staff; but even if the physician
applies them, they’re included in the E/M service,” explains Kevin Solinsky, CPC,
CPC-I, CEMC, CEDC, president and CEO of Healthcare Coding Consultants LLC in
Gilbert, Ariz.
If, however, your dermatologist uses sutures, staples, or tissue adhesives to close the
laceration, consider it a separate procedure. Choose your code from 12001-12007
(Simple repair of superficial wounds of scalp, neck, axillae, eternal genitalia, trunk
and/or extremities [including hands and feet] …) or 12011-12018 (Simple repair of
DERMATOLOGY
CODING ALERT
DERMATOLOGY
CODING ALERT
The Coding Institute
The practical adviser for ethically optimizing coding reimbursement and efficiency in dermatology practices
Vol. 5, No. 2 (Pages 9-16)
What’s Inside
Count HPI, or Risk
Choosing the Wrong E/M
Level ................................11
How many of the essential 8
questions did your physician
document?
Is Your Everyday Coding in
Sync With Payer Rules? ..13
2 quick scenarios let you
brush up on re-excision and
measurement skills.
You Be the Coder ............13
• Lesion Destruction Versus
Biopsy
Counting It: Get Your HPI
Coding Answers Here......14
Check yourself against the
scenarios on page 12.
Reader Questions
Clarify POS Codes for
Mobile Services ...............14
V Code Applies for Yearly
‘Wellness Check’ .............15
Multiple Punch Biopsies
Are Legit..........................15
Don't Turn to 'Unlisted'
for Keloid Removal .........15
Consider Timing, Location,
Intent for Skin Biopsy .....15

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superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes …), based on the lesion’s location
and size.
Medicare exception: Guidelines change when your
physician performs a single-layer laceration repair on a
Medicare patient. You’ll report G0168 (Wound closure
utilizing tissue adhesive[s] only) instead of reporting
standard CPT codes. If your physician uses sutures instead
of tissue adhesive for Medicare patients, turn back to the
standard suture/repair codes, says Jill M. Young, CPC,
CEDC, CPC-IM, with Young Medical Consulting LLC in
East Lansing, Mich.
Go Deeper With Intermediate Repair
When you see the term “intermediate repair,” it means
your physician performed one of two things:
• Layered closure of one or more deeper layers
(subcutaneous and superficial fascia/non-muscle) in
addition to skin; or
• Single-layer closure of heavily contaminated wounds
requiring extensive cleaning.
CPT revised code descriptors for intermediate repair
in 2009, shifting from the old verbiage of “layer closure of
wounds” to starting each descriptor with “Repair,
intermediate …” The change was made so that all three
levels of repair had consistent wording. Find your
intermediate repair codes at 12031-12037 (Repair,
intermediate, wounds of scalp, axillae, trunk and/or
extremities [excluding hands and feet …); 12041-12047
(Repair, intermediate, wounds of neck, hands, feet and/or
external genitalia …); and 12051-12057 (Repair,
intermediate, wounds of face, ears, eyelids, nose, lips
and/or mucous membranes …).
Better descriptor: Until 2009, intermediate codes
were the only ones that mentioned layered closure. This
tripped up some coders when filing repair claims, so the
updated terminology removes any confusion.
Wound cleaning doesn’t automatically equal an
intermediate-level repair, however.
“Most lacerations will have some degree of particulate
matter removed,” says Arnold. “In order to assign an
intermediate repair, the work involved in removing the
matter must be extensive and above what is considered
normal removal or cleaning.”
In other words: If you classify a procedure as
intermediate because of the contamination level and
cleaning, be sure you have the documentation to back it
up. Carriers will want notes regarding how extensive the
wound was, the level of work involved in cleaning, and
the amount of time spent on the procedure.
Look for any verbiage that will help describe the extra
work involved, Arnold advises. “The use of words like
‘extensive,’ ‘heavily contaminated,’ ‘large,’ or ‘copious
amounts’ of particulate matter or debris will all help the
carrier understand that the cleaning is above and beyond
that of a normal wound preparation.
Page 10 Get CPC® certified in 4 days — CodingCert.com Vol. 5, No. 2/Dermatology Coding Alert

3. Sort Through Complex Repair Choices
Complex repair procedures are more than multi-
layered closure and include a wide range of possibilities
such as scar revision or involved debridement.
“Complex repair generally includes extensive
undermining, stenting, or retention sutures,” Young adds.
“Complex repair is very time-consuming.”
The complex repair codes are broken into more
families, helping your coding be more accurate:
• 13100-13102 — Repair, complex, trunk …
• 13120-13122 — Repair, complex, scalp, arms and/or
legs …
• 13131-13133 — Repair, complex, forehead, cheeks,
chin, mouth, neck, axillae, genitalia, hands and/or
feet …
• 13150-13153 — Repair, complex, eyelids, nose, ears
and/or lips …
• 13160 — Secondary closure of surgical wound or
dehiscence, extensive or complicated.
Consider more than layers when you think it’s time to
report complex repair codes. Your physician’s documen-
tation should include notes about correcting a defect,
performing extensive tissue debridement, or even creating
a defect in order to repair a problem.
For example, plastic surgeons tend to perform many
complex repairs because the wounds they close often
require a lot of preparation with undermining, retention,
and debridement of large skin areas. Many times they use
a layered closure technique.
What it’s not: Sometimes your physician might
perform lesion excision as part of a complex repair. The
repair codes do not include excision, so in those situations
you’ll report separate codes for the excision and repair.
“Excision of lesions is not included in complex repair
and therefore would be coded separately,” Arnold
explains. “However, intermediate or complex closure of a
lesion removal (benign or malignant) is not included as
part of lesion removal, either. As long as the closure is
intermediate or complex, you should also apply a separate
charge for the closure.”
Example: Your physician removes a 2.5 cm benign
lesion (including margins) from the patient’s mid-back. He
closes the wound in layers after extensive irrigation and
undermining of tissues. When filing the claim, you should
report 11403 (Excision, benign lesion including margins,
except skin tag [unless listed elsewhere], trunk, arms or
legs; excised diameter 2.1 to 3.0 cm) for lesion excision
and 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm) for
complex repair.
Final advice: “Look at the provider’s closure
description and do not code by the wound description,”
Arnold notes. “Many providers may describe a complex
wound but then close it with a simple technique.” ❑
Count HPI, or Risk Choosing
the Wrong E/M Level
How many of the essential 8 questions
did your physician document?
If you’re like many dermatology coders, you
sometimes have trouble understanding the elements of
history of present illness (HPI) and why it’s important to
count them. Here’s your quick run-down of why—and
how—to correctly count HPI elements, plus examples
straight from a dermatology coder’s desk.
Count to Move From ‘Brief’ to ‘Extended’
You need to count HPI elements because they’re an
important part of the history component of E/M services.
A brief HPI consists of one to three elements, whereas an
extended HPI requires four or more elements.
Your dermatologist must perform an extended HPI in
order to satisfy the requirements for a detailed or compre-
hensive history. Reaching an extended HPI does not
guarantee that you can report a high-level E/M code —
your physician must still satisfy the other elements of the
service before you choose a high-level code. Having the
extended HPI is one step toward that possibility.
(Continued on next page)
Definitions Made Easy
Do you have trouble knowing where to draw the
line between layers of skin repair? Here’s a back-to-
basics explanation from Jill M. Young, CPC, CEDC,
CPC-IM, with Young Medical Consulting LLC in East
Lansing, Mich.:
“Simple repair is used when the wound is superficial
(e.g., involving primarily the epidermis or dermis). If
the wound additionally requires layer closure of one or
more layer, then it is intermediate. If you do more than
layer closure, that is complex.”
Dermatology Coding Alert/Vol. 5, No. 2 To subscribe, call (800) 508-2582 Page 11

4. For coding purposes, HPI is an ordered description of
the patient’s current malady.
“Dermatology HPIs can be a little more challenging
than with some other specialties, in that there are not
always problems,” says Sandy Adams-Stevens, a
coding/documentation specialist with Heritage Medical
Associates in Nashville, Tenn. “Some patients have
problems, but some are only there for a ‘skin check.’ Of
course, if they don’t really have a problem, it means it
may not be possible to support a higher-level E/M code.”
Checklist: When counting elements, see how many of
these eight questions your physician answers in the notes:
1. What is the physical location of the problem on or
in the body? (location)
2. How is the symptom further described related to the
type of pain (such as itchy or burning)? (quality)
3. How intense is the problem or related pain?
(severity)
4. How long has the patient had the problem?
(duration)
5. Is the problem better or worse at any time of the
day? (timing)
6. How did the injury occur? (context)
7. What can the patient do to alleviate or aggravate the
pain? (modifying factors)
8. What other symptoms and signs does the patient
have in relation to the chief complaint? (associated signs
and symptoms)
Note: CPT does not include duration in its list of HPI
elements, so it has seven elements.
Clue In to Special Considerations
With two sets of E/M guidelines to choose between
(1995 and 1997), ensuring your documentation stays on
track can be tricky for anyone. You have other things to
keep in mind, however, when you deal with dermatology.
“The standard exam established for dermatology
includes only three organs/systems, based on the 1995
guidelines—constitutional, ENT, and skin,” Adams-
Stevens says. “However, you have 16 bullets within those
organs/systems, based on the 1997 guidelines. My advice
to our dermatologists has been to reach the level of exam
by examining elements within the system(s); that is, they
count bullets from 1997 instead of organs/areas in the
1995 guidelines.”
Higher level tip: The integumentary system
guidelines include only 12 recognized bullets (including
eccrine/apocrine glands, which Adams-Stevens says are
rarely examined). You have a total of 16 bullets
recognized within the three dermatology organs/systems,
however, so your provider only needs to examine two
more bullets/elements for a total of 18 to qualify for
comprehensive exam coding.
Caution: Although the math might work that way,
Stevens-Adams stresses that she’s not suggesting that
providers gather more history than needed or examine
more than medically necessary.
“I'm only explaining documentation guidelines,” she
says. “The well-being and clinical outcome of our patients
are the utmost concern, no matter the documentation. The
amount of history and exam should be commensurate with
the nature of the problem and overall risk, which means it
might not always be possible to support higher levels of
E/M codes.”
“I have a personal belief that once you hit four, you
stop,” adds Pamela J. Biffle, CPC, CPC-I, CCS-P,
CHCC, CHCO, owner of PB Healthcare Consulting and
Education, Inc., in Watauga, Tex. “You hit the maximum
for coding and identifying more is not time-efficient.”
Put the Pieces Together
Reading a list of criteria is one thing; seeing how they
might come together in a case is another. Test yourself by
coding the following scenarios.
Example 1: Problem-oriented visit
CC: Spot on back
HPI: Pt presents today for a spot on his back
(location); his wife just noticed it, so they’re unsure how
long it’s been there (duration). He says he’s not out in the
sun much, and when he is, he doesn’t [or does] use sun
block (modifying factors); he denies that it bothers him in
any way, e.g., with clothing (sign/symptoms).
One of the reader questions in Dermatology
Coding Alert, Vol. 5, No. 1, listed an incorrect CPT
code. In “Biopsy one day, excision later = 2
procedures,” the code should be 11100, not 11110
(which is a nonexistent code). The descriptor in the
answer (Biopsy of skin, subcutaneous tissue and/or
mucous membrane [including simple closure], unless
otherwise listed; single lesion) is correct for 11100.
Correction
Page 12 Get CPC® certified in 4 days — CodingCert.com Vol. 5, No. 2/Dermatology Coding Alert

5. ROS: (Skin) denies itching; (Allergy/Immunologic)
denies allergic or immunologic issues.
PFSH: No family history of skin cancer.
Example 2: Skin check with no known problem
CC: Skin check
HPI: Pt presents today for a skin check, without any
complaints. She has not noticed any spots on any part of
her body, nor does she have any issues that particularly
concern her (location). She has Fitzpatrick skin type V;
tans very easily (modifying factors).
ROS: (Skin) denies problems; (Allergy/Immunologic)
denies allergic or immunologic issues.
PFSH: No family history of skin cancer.
Once you determine your answers, turn to page 14 to
see what our experts recommend. ❑
Is Your Everyday Coding in
Sync With Payer Rules?
2 quick scenarios let you brush up on
re-excision and measurement skills.
Lesion excision coding is one of the mainstays for
dermatology, but frequently-changing carrier guidelines
mean you need to pay close attention to each claim. Check
out the following scenarios and coding advice to ensure
you’re reporting procedures correctly.
1. Re-Evaluating Narrow Margins
Scenario: Patient A came to your office to have a
suspicious-looking lesion removed. The pathology report
showed a malignant lesion. Your physician performs an
additional excision within the first procedure’s global
period to ensure the removal includes clear margins. How
should you report the encounter to your payer?
Answer: Because your physician never knows for
certain whether a lesion is malignant or benign when he
removes it, wait for the pathology report before coding.
“Coders are taught to use the most accurate code
possible when sending a claim,” says Joseph Lamm, office
manager with Stark County Surgeons in Massillon, Ohio.
“While a doctor may be reasonably certain that a lesion is
benign or malignant based on her extensive experience, the
final word is based on the pathology report.”
Choose from the 116xx section (Excision, malignant
lesion) to report the excision because of the malignancy.
Once you select the appropriate code, list it twice —
you’re reporting two excisions and should consider both
malignant even if the second pathology report is negative.
“A re-excision of the area would require modifier 58
(Staged or related procedure or service by the same
physician during the postoperative period) on the CPT
code if it was done within the global period,” says Lamm.
Note: CPT indicates that you should use only one
code to report the additional excision and re-excision(s)
required for complete tumor removal.
“To me, that says that the additional excision and any
further re-excisions should not be billed until pathology
shows complete excision of the tumor,” Lamm says. “I
read it as the additional excision and re-excisions should
be billed based on the width necessary from the original
wound (i.e., not taking into account the lesion and margins
from the initial excision).”
2. Counting Correct Measurements
Scenario: Your dermatologist excises a benign lesion
from Patient B’s scalp. The greatest clinical diameter of
the lesion is 2.4 cm, and the procedure required margins of
0.4 cm on each side. How should you bill the procedure?
Answer: According to CPT guidelines, an excision is
defined as full-thickness (through the dermis) removal of a
lesion, including margins (your physician should measure
the lesion and margins before excision). Excision codes
include simple (non-layered) closure.
“A key in dermatology is that the excision must
capture the size of the lesion and the size of the defect to
(Continued on next page)
Lesion Destruction Versus Biopsy
Question: How should we bill for a biopsy when we
submit it to a pathologist? Our dermatologist treats
basal cell carcinoma with destruction, but also always
performs a biopsy.
Nevada Subscriber
Answer: Turn to page 15 for the answer. ❑
You Be the CoderYou Be the Coder
Dermatology Coding Alert/Vol. 5, No. 2 To subscribe, call (800) 508-2582 Page 13

6. Clarify POS Codes for Mobile Services
Question: Our dermatologist and nurse practitioner
will be using a mobile van to conduct skin cancer screen-
ings in multiple locations (nursing homes, supermarkets,
parks, etc.). Can we bill for a screening/office visit along
with a biopsy or treatment when needed? What place of
service codes should I use?
Missouri Subscriber
Answer: You will need to include the correct place of
service codes with the claims, depending on where your
physician sees the patients. For example, report POS 13
for an assisted living facility, POS 31 for a nursing home,
or POS 04 for a homeless shelter. If your physician
conducts the screenings in the mobile van itself, look to
POS 15 (Mobile unit).
As long as your physician’s documentation supports
an E/M service with a biopsy and/or treatment, you can
bill both services when appropriate. Remember to append
modifier 25 (Significant, separately identifiable evaluation
and management service by the same physician on the
accurately pick a code,” explains Jennifer Swindle,
CPC, CPC-E/M, CPC-FP, RHIT, CCP-P, director of
coding and compliance for PivotHealth LLC in
Brentwood, Tenn.
The lesion in this case is 2.4 cm. Once you add 0.8
centimeters for the margins, you reach a total
measurement of 3.2 cm. You’ll report code 11424
(Excision, benign lesion including margins, except skin tag
[unless listed elsewhere], scalp, neck, hands, feet,
genitalia; excised diameter 3.1 to 4.0 cm).
Checkpoint: “That’s a pretty big lesion, so the
surgeon might have used layered closure,” Lamm says.
“If it’s indicated in the documentation, you should code
for it along with the lesion excision.” Also append
modifier 51 (Multiple procedures) because the closure is
related to the excision. ❑
READER QUESTIONS
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Counting It: Get Your HPI
Coding Answers Here
Check yourself against the scenarios
on page 12.
Example 1: Problem-oriented visit
In a new patient, this would be a detailed history, a
level-three history with only two ROS (even though
many physicians obtain a complete ROS and PFSH on
a new patient). This example shows only information
relevant to the presenting problem.
This visit supports 99203, if it were based on the
patient’s history (one of the “3 of 3” key components
required in a new patient visit), according to Sandy
Adams-Stevens, a coding/documentation specialist
with Heritage Medical Associates in Nashville, Tenn.
For an established patient, a detailed history is known
as a level-four history.
Example 2: Skin check with no known problems
In a new patient, this would be an expanded, level-
two history with only two elements (although many
physicians obtain a complete ROS and PFSH on new
patients). This example shows only information
pertinent to the reason for the patient’s visit.
This visit supports 99202 for a new patient if you
base your coding on patient history. For an established
patient, an expanded, problem-focused history is
considered a level 3 history. ❑
Page 14 Get CPC® certified in 4 days — CodingCert.com Vol. 5, No. 2/Dermatology Coding Alert

7. (Continued on next page)
same day of the procedure or other service) to the E/M
code to indicate it’s separate from the E/M service.
V Code Applies for Yearly ‘Wellness Check’
Question: A patient says her insurance provider did
not pay our bill for her yearly skin exam because we
“didn’t have the wellness code down.” She had her first
exam and diagnosis last year; should we have reported a
V code instead?
Texas Subscriber
Answer: Yes, a V code might be a better choice,
especially if the patient has a history of skin cancer. In
those cases, consider V76.43 (Special screening for
malignant neoplasms; skin) for visits your dermatologist
documents as a “skin check.” If the patient’s original
screening was malignant, list the screening code as
primary and a personal history code such as V10.82
(Personal history of malignant neoplasm of other sites;
malignant melanoma of skin) or V10.83 (… other
malignant neoplasm of skin) second.
“Worried well”: What if the patient returns several
times each year because she is worried about skin cancer
but has no signs of it? Submit V65.5 (Person with feared
complaint in whom no diagnosis was made) as the
diagnosis or code based on any symptoms listed in the
patient’s HPI.
Multiple Punch Biopsies Are Legit
Question: Can we code multiple punch biopsies on a
single claim? Our dermatologist sent 11 punch biopsies of
the patient's right ear to pathology for testing.
New Hampshire Subscriber
Answer: Yes, you can code multiple punch biopsies
on the same claim; just list each on a separate line to
clarify the procedure for your carrier. Report 69100
(Biopsy external ear) for the first punch and append
modifier 59 (Distinct procedural service) for biopsies 2
through 11. You can either list each biopsy individually or
can code 69100, 69100-59 x 10. Before filing the claim,
verify whether your carrier has a preference for which
option you choose.
Don't Turn to 'Unlisted' for Keloid Removal
Question: Does CPT include a code for removing a
keloid scar? If not, should I report the service as an
“unlisted” procedure?
Michigan Subscriber
Answer: No, you don’t need to resort to 17999
(Unlisted procedure, skin, mucous membrane and
subcutaneous tissue). Instead, you can report a procedure
code based on how your physician removes the keloid —
his method of destruction or excision. Submit the
procedure code with diagnosis 701.4 (Keloid scar).
Consider Timing, Location, Intent for Skin Biopsy
Question: How do I know when to report skin biopsy
separately with, or in place of, other procedures such as
shaving or excision?
California Subscriber
Answer: In general, you may report skin biopsy
(11100-11101, Biopsy of skin, subcutaneous tissue and/or
mucous membrane [including simple closure], unless
otherwise listed …) separately when the biopsy occurs at a
separate location from an excision or other removal or
when the results of the biopsy prompt the more extensive
removal by excision or other method.
For instance, if your physician excises a lesion on the
patient’s right hand and biopsies a different lesion (either
(Question on page 13)
Lesion Destruction Versus Biopsy
Answer: Biopsy and destruction are mutually
exclusive, which means you cannot bill them together if
they were completed during the same session. The
destruction is the higher-level procedure, so only report
it. Choose the appropriate code from 17260-17286 for
destruction of malignant lesions (based on the lesion size
and location). ❑
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Dermatology Coding Alert/Vol. 5, No. 2 To subscribe, call (800) 508-2582 Page 15

8. Editorial Advisory Board
Tina S. Alster, MD
Director
Washington Institute of
Dermatologic Laser Surgery
Arthur K. Balin, MD, PhD,
FACP
Senior Physician
The Sally Balin Medical Center
for Dermatology and Cosmetic
Surgery
Pamela Biffle, CPC, CPC-I,
CCS-P, CHCC, CHCO
Owner
PB Healthcare Consulting and
Education, Inc.
Cathy Klein, LPN, CPC
President
Klein Consulting
Christine M. Liles, CPC
Insurance Supervisor
Knoxville Dermatology Group
PC
Janet McDiarmid, CMM, CPC,
MPC
Past President
American Academy of Profes-
sional Coders
Tracy Smith
NC Center for Dermatology
Teresa M. Thompson, CPC
TM Consulting
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on the right hand or elsewhere on the body), the excision and biopsy are separate.
Append modifier 59 (Distinct procedural service) to the biopsy code to show that it
occurred at a different location from the excision.
Don’t forget: Biopsy is a standard practice when removing skin lesions. In most
cases, you would not report biopsy of the same lesion separately with an excision or
other removal. In an alternative scenario, the physician takes a biopsy by shave
technique and submits the sample to pathology for examination. The results reveal a
malignant lesion, which your physician then removes in its entirety, with margins, by
excision. In this case, the biopsy and excision are again separate because the biopsy
led to the decision for the excision.
When coding, append modifier 58 (Staged or related procedure or service by the
same physician during the postoperative period) to the excision code to show that this
was a staged procedure following the biopsy.
Important: Your physician’s intent has a lot to do with distinguishing between a
biopsy and removal by shaving, excision, or some other method. The AMA has
stressed this point, noting, “The intent of a biopsy is to remove a portion of skin,
suspect lesion, or entire lesion so that it can be examined pathologically” (CPT
Assistant, Vol. 14, Issue 10: Oct. 2004). In contrast, “The intent of other integu-
mentary procedures that involve removal of tissue is different. Generally, they are
performed for the purpose of removing the entire lesion.”
Because physicians often use the terms “biopsy” and “excision” interchangeably,
you may find questioning your doctor on those claims useful when the terminology
and intent are unclear.
— Technical and coding advice for You Be the Coder and Reader Questions
provided by Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB
Healthcare Consulting and Education Inc. in Watauga, Texas. ❑
Page 16 Get CPC® certified in 4 days — CodingCert.com Vol. 5, No. 2/Dermatology Coding Alert