Dermatology Coding: Utilizing Modifiers to Ensure Accuracy

Dermatology is one of the more complex specialties in medical billing and coding, with a wide range of procedures that can be performed either in the office or in the same day surgery setting. An in-depth understanding of dermatology CPT codes and the appropriate use of modifiers is crucial to ensure accurate coding and reimbursement.

Modifier 59

Modifier 59, Distinct Procedural Service, should be used to identify procedures that are not normally reported together but are appropriate under certain circumstances. According to the AMA CPT Manual, documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury (or area of extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Example: Cryosurgery is performed on an actinic keratoses lesion (17000). A shave biopsy is also performed during the same session on a mole (11102).

Coding: 11102, 17000-59

Distinct X Modifiers

In 2015, CMS developed four new modifiers to define subsets of the 59 modifier. These modifiers can be used in place of modifier 59 when the documentation in the medical record is supported.

XE- Separate Encounter

Used to identify procedures performed in the same patient visit or procedure session.

Example: A 2.0cm intermediate repair of a facial laceration (cheek) is performed in the Emergency Department (12051). The patient is then taken to the Operating Room for a 2.7cm intermediate repair of the eyelid (12052).

            Coding: 12052, 12051-XE

XS- Separate Structure

Used to identify procedures performed on a different body site/region/organ system.
Example: A punch biopsy of a facial lesion (11104) that was distinct from the excision of a separate benign lesion on the arm. The benign lesion measured 1.3cm and included simple repair (11402).

            Coding: 11402, 11104-XS

XP- Separate Practitioner

Used to identify procedures performed by different practitioners.

Example: One physician in a practice performs a service and another physician in the same specialty from the same practice performs a normally bundled service on the same patient, for medically necessary reasons.

Possible Scenario: The patient is seen in the dermatologist office by an NP for a highly suspicious mole. After a biopsy is performed (11104), the NP arranges for immediate transfer to another physician in the practice to perform the needed excision of the same lesion (11602).

Coding: 11602, 11104-XP

XU- Unusual Non-Overlapping Service

Used to indicate a service that is distinct because it does not overlap usual components of the main service.

Example: A patient is put under anesthesia for surgery (00400). During surgery, the patient codes, requiring CPR as an emergency procedure (92950).

            Coding: 00400, 92950- XU

Note: Modifier XU is not typically used in the dermatology setting.

Modifier 25

Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) is one of the most common modifiers used in dermatology offices. Frequent use of modifier 25 can be appropriate dermatology practices, but it is important to ensure the modifier is being used correctly.

Modifier 25 is used to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

Example: An established patient comes in for a suspicious mole which is biopsied. However, during the visit the patient mentions he/she has a leg rash. The leg rash is also examined and treated. A separate E/M code with the “25” modifier is appropriate.

Note: Modifier 25 should only be used with E/M codes for established patients (not new patients) and never with procedure codes.

Additional Information

Additional information regarding dermatology procedures and associated modifiers can be found below:

• American Medical Association (AMA) CPT 2021 Manual, Professional Edition

ISBN 978-1-64016-056-9

• CMS: The Medicare Learning Network® Fact Sheet- Proper Use of Modifiers 59 & -X{EPSU}

https://www.cms.gov/files/document/proper-use-modifiers-59-xepsu.pdf

• AAPC Knowledge Center: Specific Modifiers for Distinct Procedural Services https://www.aapc.com/blog/29197-specific-modifiers-for-distinct-procedural-services-from-cms/
• MD Edge Dermatology: Modifier -25 Use in Dermatology

https://www.mdedge.com/dermatology/article/97148/practice-management/modifier-25-use-dermatology

• Coding Clinic for HCPCS, Second Quarter 2018 Pages: 1-2: Modifier 59 subsets, correct reporting
• Coding Clinic for HCPCS, First Quarter 2015 Pages: 1-2: X modifier implementation
• Coding Clinic for HCPCS, First Quarter 2009 Pages: 1-4: E/M coding guidelines