There are new soft tissue codes available that I
believe include the closure. Why would you bill a
soft tissue CPT if the RVUs are less than the
combined RVUs on an excision and intermediate
The code selected must be the one that best describes the treatment, therefore the correct code to use for excision of soft tissue is a soft tissue excision code. It is true that the soft tissue excision codes include simple or intermediate repair, as explained in CPT at the front of the musculoskeletal section. Several of these codes are new for this year and appear out of numerical sequence in CPT. Rather than being listed by type of service, as are the codes for the integumentary system, the soft tissue codes are listed by body site.
Let's take a look at a fee schedule comparison between the integumentary codes and the musculoskeletal codes using the Medicare fee schedule for North Carolina for a patient with a 4cm (including margins) lipoma on the left arm:
The integumentary codes and associated values would be:
The multiple surgery reduction rule will reduce the excision code by half, so the total reimbursement amount would be $361.59 ($92.75+268.84).
The musculoskeletal code and associated value would be:
Of note, not all comparisons resulted in a higher reimbursement for the musculoskeletal codes, but the differences were under $20.00 on the ones we checked.
Therefore, rest assured you would not lose by choosing the correct codes. But be aware that the soft tissue excision codes have 90 post-op days.
If we have a patient with a personal history of
malignant melanoma, isn't that visit always 99214?
An E/M code is never chosen by a patient's diagnosis alone but by what work must be done to address the patient's presenting problem. Using the 1997 rules, 99214 requires at least 12 bulleted areas examined. That is usually easy to accomplish, but either the history or the medical decision-making must also be satisfied to support the code.
The history requirement for 99214 is at least four elements of HPI, at least two ROS, and one element of past, family, or social history.
The medical decision-making has three separate sections, two of which must be met. The Number of diagnoses and management options requirement is “Multiple.” Amount and complexity of data to be reviewed refers to results of tests ordered, old records (not your own) that must be examined, or obtaining a history from sources other than the patient. The requirement for 99214 is “Moderate.”
The third part, Risk is based on the risks associated with the presenting problem, diagnostic procedures, and possible management options. The requirements are fairly strong. So be sure to examine all of the documentation and requirements before selecting a code.