EXCISION OF SKIN LESIONS
I have been told I must hold code selection and billing for excising skin lesions until we receive the pathology report to confirm whether an excised lesion was benign or malignant. Is that correct?
Yes, to a point. Current CPT guidance is to delay coding and billing until the pathology has been confirmed, unless the excised lesion is clearly benign or clearly malignant. This is true regardless of the method of excision. If you are confident the lesion is clearly benign or clearly malignant, you may code it as such up front and then file a revised claim if the pathology report says otherwise.
For ICD-10 coding, when you're unsure whether the lesion is benign or malignant, either hold the claim until the pathology report is available or submit an unspecified diagnosis code. Do not report codes for neoplasms of uncertain behavior unless the pathologist's report reflects that (e.g., a lesion that may be transitioning to malignancy).
MEDICARE COVERAGE OF IMMUNIZATIONS
What immunizations are covered under Medicare Part B?
Medicare Part B covers routine immunizations against COVID-19, pneumococcal illness, hepatitis B, and influenza. (Other routine recommended immunizations, such as RSV and zoster, are covered under Part D.) When reporting routine immunization, use the appropriate CPT code for the vaccine product and an appropriate immunization administration code:
- 90480 for administration of COVID-19 vaccine,
- G0008 for administration of influenza virus vaccine,
- G0009 for administration of pneumococcal vaccine,
- G0010 for administration of hepatitis B vaccine.
Link diagnosis code Z23 (encounter for immunization) to the vaccine product and administration codes. You may report other ICD-10 codes secondary to Z23 to indicate immunization in patients who have an underlying condition or other risk factor such as diabetes mellitus or end-stage renal failure.
Medicare Part B also covers non-routine vaccines, antitoxins, antivenin sera, and immune globulins administered to treat injury or direct exposure to a disease or condition (e.g., tetanus antitoxin or vaccine booster). Link a diagnosis code for the injury or other condition (e.g., S91.331A for puncture wound without foreign body, right foot, initial encounter) to the product and administration codes (e.g., 90471, immunization administration by injection).
E/M COMPLEXITY CODE G2211 FREQUENCY
Is there a frequency limitation for the G2211 “visit complexity” add-on code?
No, the Centers for Medicare & Medicaid Services (CMS) did not set a frequency limitation. CMS noted in the 2024 Medicare Physician Fee Schedule final rule that it expects primary care specialties to have higher G2211 utilization than others. Like any office visit, the visits you report in conjunction with G2211 must be clinically indicated and must be provided either in the context of a longitudinal care relationship or as part of ongoing care related to a patient's single, serious condition or complex condition. If office visits take place at a frequency or for a purpose beyond what is reasonable and necessary for the patient's health care needs, Medicare may deny the claim, initially or retroactively after payment. For more information, see “G2211 Update and Infographic: When to Use the Visit Complexity Add-On Code” in the January/February 2025 issue of FPM.
NO FOREIGN BODY FOUND IN EYE
What diagnosis code should I report when a patient presents with concern about a foreign body in their eye, but I don't find any foreign body?
It depends on why the patient is concerned. ICD-10 includes codes for foreign body sensation (e.g., H57.8A1 to H57.8A3 for eyes). When the patient suspects that something entered their eye (e.g., wood shavings) but has no symptoms (including no sensation), you may report a code from category Z04 to indicate the condition was ruled out after examination (e.g., Z04.2 for examination following a work accident).
