INSURANCE ISSUES: SKIN LESIONS: RECOMMENDED CRITERIA FOR THIRD-PARTY PAYER COVERAGE

Background:
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.

Definitions:
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.

Procedure
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, 27615, 28046.

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:
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 previously.

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.

Position Statement:
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 payers.

References:
Casson, P., et al. "Dysplastic and Congenital Nevi." Clinics in Plastic Surgery, 20(1):105, 1993.

Janevicius, R. "Coding for Lesion Excisions Clarified." Plastic Surgery News, June, 1993.

Kaplan, E.M. "The Risk of Malignancy in Large Congenital Nevi." Plastic and Reconstructive Surgery, 53:421, 1972.

Marks, R., et al. "Malignant Transformation of Solar Keratoses to Squamous Cell Carcinoma." Lancet 1 (8589):795, 1988.

Pinkus, H. "Premalignant Fibroepithelial Tumors of the Skin." Archives of Dermatology 67:598, 1953.

Pollack S.V., et al. "The Biology of Basal Cell Carcinoma: A Review." Journal American Academy of Dermatology, 7:569, 1982.

Robinson, J.K. "Risk of Developing Another Basal Cell Carcinoma." Cancer 60:18, 1987.

Thompson, H.G. "Common Benign Pediatric Cutaneous Tumors: Timing and Treatment." Clinics in Plastic Surgery, 17(1):49, 1990.

Vitagliano, P., et al. "The Relative Importance of Risk Factors in Nonmelanoma Carcinoma." Archives of Dermatology, 16:454, 1980.