So, I got an email from a client, with a great question and thought I would share our reply!
The Question: What the average insurance pay-out is for a small in office cyst or lipoma removal. Wondering if we should be submitting or billing cosmetically?
Good question. They are medically necessary procedures typically so you should be billing them technically. Now if a patient is comfortable paying out of pocket for a cash pay price and prefers to do so, that is their prerogative.
Some info on the coding/payout…
Ballpark Rules: ⚙️⚙️⚙️
Cyst = excision + closure
Lipoma = soft tissue excision code
The line between the use of soft tissue excision codes versus excision codes is goofy (stupid if I’m being honest), and is defined by where the lesion originates NOT where you “cut” to. This is illogical to me because the work done is dependent on the work done…not whether or not the lesion originates in the dermis. Be that as it may…
You CAN bill an excision with an intermediate OR complex closure. You CAN ONLY bill a complex closure with a soft tissue excision.
Ballpark Numbers: 💰💰💰
Common Issues: 💀💀💀
Intermediate repair includes the repair of wounds that, in addition to the above, require 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.
Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions.
Under-coding Soft Tissue Excisions: Don’t bill it as an excision just to get the intermediate closure revenue…you’re too close to a net even on revenue per procedure to risk a common coding error.
Common Denial BS: Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation. But, guess what, you’re going to see bundling denials all the time. If you put a 59 on one code, they’ll deny the other. Flip it around, and the payers will do the same. Put a 59 on both and you’re “over-modifying” but the claim may slide through…and you risk an audit doing this at volume. Welcome to billing…you’re damned if you do…and/or if you don’t.