Download Milia Treatments: Pop These Milia Myths Before They Blemish Your

Chapter 3: Dermatology
Milia Treatments: Pop These Milia Myths Before
They Blemish Your Reimbursement
Know the difference between 10040 and 17110.
Milia treatments can be notoriously challenging to report, in part because it can be difficult to discern between acne
surgery codes and destruction codes. Is one of these four myths causing reimbursement hassles in your dermatology
practice?
Myth: 10040 and 17110 Are Interchangeable
Reality: The main difference between 10040 (Acne surgery — e.g., marsupialization, opening or removal of multiple
milia, comedones, cysts, pustules) and 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery,
chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions;
up to 14 lesions) is that the 17110 code is a destruction while the 10040 code is a removal.
The code 10040 states that an incision is made into the cyst or milia for removal and code 17110 is for destruction.
Hint: In CPT®, any code with a prefix of “17” is a destruction code. As mentioned in 17110’s description, the most
common forms of destruction include the application of liquid nitrogen or other chemical agent (a.k.a. cryosurgery),
curettage, electrodessication, or the use of a laser.
Meanwhile, your dermatologist usually removes a milia by using a comedone extractor, which is a tool not much bigger
than a pair of tweezers.
Cost: Don’t get tempted to report one code over the other just because of potential payback figures. Based on
Medicare rates, code 10040 pays back $101.74 while 17110 comes in at $109.26. Also, you should always be aware
that some payers may not consider treatment of milia as a medically necessary procedure.
Caveat: “It is common to use a lancet before using a comedone extractor,” says Pamela Biffle, CPC, CPC-P, CPC-I,
CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. “I would never suggest using 10040 in
that instance.”
Myth: You Can Code 17110 and 17111 Together
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Reality: The series 17110-17111 specifies the destruction of benign lesions that is medically necessary. If you’d use a
destruction code to report milia treatment, you should remember that 17110 is for up to 14 lesions while 17111
(...15 or more lesions) is for 15 or more lesions treated at one time. Thus, you will never code 17110 and 17111
together at any given time on any particular patient.
Red flag: When assigning codes for benign or premalignant lesions, the number of lesions matters. Furthermore, an
appropriate ICD-9 code should come with reporting 17110-17111. Some of the most common include 702.11 (Inflamed
seborrheic keratosis), 078.10 (Viral warts, unspecified), 706.2( Sebaceous cyst) to which group milia belongs, and
078.19 (Other specified viral warts [e.g., common wart, flat wart, verruca plantaris]).
Extra: Dermatologists may also report 17110-17111 with 216.x (Benign neoplasm of skin) and 238.2 (Neoplasm of
uncertain behavior of skin).
Myth: The Path Report Isn’t Important
Reality: Milias are tiny white bumps of keratin in the glands of the skin. They are common in newborns’ faces —
usually on the tip of the nose or chin — but are also found in adults. Medicare and most carriers have a benign lesion
destruction/removal policy that you must meet in order to bill milia treatment. Look out for the proper symptoms that
should be indicated in your dermatologist’s pathology report, such as:
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inflammation
bleeding
clinical suspicion for malignancy
pain
irritation (various carriers differ on policies for this symptom).
ICD-10: Keep Clear of Viral Warts Diagnosis Confusion
In 2015, start with the B07.- series for viral warts.
For the most part, dermatology coders will be relieved to know that there is a one-to-one correlation between ICD-9
codes and ICD-10 codes for diagnoses of viral warts. All but one of the ICD-9 codes in the 078.1x (Viral warts) series
maps to the B07.- (Viral warts) category in ICD-10. On Oct. 1, 2015, these are the new viral wart categories you’ll have
to contend with.
Learn more: For more information on the ICD-10 conversion, as well as specific ICD-9 to ICD-10 code bridges,
CPT © 2015 American Medical Association. All rights reserved.
Vein Treatments: Verify Varicose Vein Necessity and Earn Deserved Pay
Spider vein and varicose vein treatments are increasingly common procedures at dermatology practices — and just as
common are the struggles to code and bill them correctly. If a vein treatment is medically necessary, follow the expert
advice below to get your deserved reimbursement.
Know the Sclerosing Solution Injection Basics
The problematic veins your dermatologist is most likely to be faced with fall into two categories: spider veins and
varicose veins, says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education Inc.
in Austin, Texas.
Spider veins: Also known as telangiectases or roadmap veins, these are “very tiny superficial blood vessels that
increase in size over time and commonly occur on the legs,” according to the American Academy of Dermatology.
Varicose veins: These are larger, dilated blood vessels that can be raised above the skin’s surface and have a ropelike appearance, the AAD says.
Treatment: A common treatment is an injection of a medicine into the affected blood vessels to shrink them. These
injections of sclerosing solutions are described with CPT® codes 36468-36471.
Medicare rules: CPT® has specific codes for sclerosing injections:
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36468 — Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
36469 — …face
36470 — Injection of sclerosing solution; single vein
36471 — … multiple veins, same leg.
However, don’t count on reimbursement from Medicare for spider vein treatments. As Part B carrier National
Government Services puts it in its local coverage determination (LCD), “Spider veins … are most often treated for
cosmetic purposes. Treatment of telangiectases is not covered by Medicare.”
Understand the Varicose Treatments
Ligation and stripping is a proven treatment for varicose veins, reported by dermatologists with CPT® codes:
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37718
37722
37780
37785
— Ligation, division, and stripping, short saphenous vein
— … long (greater) saphenous veins from saphenofemoral junction to knee or below
— Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
— Ligation, division, and /or excision of varicose veins (clusters), one leg.
Another therapy for treating varicose veins is radiofrequency, says the AAD. During this procedure, radiofrequency
CPT © 2015 American Medical Association. All rights reserved.
energy converted to heat is used to collapse the vein, which is then reabsorbed by the body, the Academy explains.
Radiofrequency is described by CPT® codes:
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36475 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and
monitoring, percutaneous, radiofrequency; first vein treated
36476 — … second and subsequent veins treated in a single extremity, each through separate access sites (List
separately in addition to code for primary procedure).
Laser therapy is one of the latest treatments for varicose veins, in which tiny laser fibers are delivered to the vein
through a needle puncture that is threaded up to the main vein trunk responsible for these veins, says the AAD. This is
described by CPT® codes:
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36478 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and
monitoring, percutaneous, laser; first vein treated
36479 — … second and subsequent veins treated in a single extremity, each through separate access sites (List
separately in addition to code for primary procedure).
Prove Medical Necessity
Although Medicare has no national coverage determination (NCD) for varicose vein treatments, several local Part B
carriers, such as National Government Services, have LCDs. NGS’s policy states that Medicare will consider
interventional treatment of varicose veins medically necessary if the patient remains symptomatic after a six-week trial
of conservative therapy. The components of the conservative therapy include, but are not limited to:
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Weight reduction,
A daily exercise plan,
Periodic leg elevation
The use of graduated compression stockings.
“The conservative therapy must be documented in the medical record,” says NGS.
The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of
the lower extremities are documented in the medical record, the Part B carrier says:
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Stasis ulcer of the lower leg
Significant pain and significant edema that interferes with activities of daily living
Bleeding associated with the diseased vessels of the lower extremities
Recurrent episodes of superficial phlebitis
Stasis dermatitis
Refractory dependent edema.
Although not limited to these diagnoses, NGS lists these ICD-9 codes as supporting medical necessity for varicose vein
treatments:
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451.0 — Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.2 — Phlebitis and thrombophlebitis of lower extremities unspecified
454.0 — Varicose veins of lower extremities with ulcer
454.1 — Varicose veins of lower extremities with inflammation
454.2 — Varicose veins of lower extremities with ulcer and inflammation
CPT © 2015 American Medical Association. All rights reserved.
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454.8 — Varicose veins of lower extremities with other complications
459.31 — Chronic venous hypertension with ulcer
459.32 — Chronic venous hypertension with inflammation
459.33 — Chronic venous hypertension with ulcer and inflammation.
Keep Your Documentation Solid
The patient’s medical record must contain documentation that fully supports the medical necessity for services,
cautions NGS. “This documentation includes, but is not limited to, relevant medical history, physical examination, and
results of pertinent diagnostic tests or procedures.”
Specifically, the LCD requires that the patient’s medical record must document:
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History and physical findings supporting a diagnosis of symptomatic varicose veins
Failure of an adequate trial of conservative treatment
Exclusion of other causes of edema, ulceration and pain in the limbs
Performance of appropriate tests to confirm the presence and location of incompetent perforating veins
Location and number of varicosities, level of incompetence of the vein and the veins involved
Necessity of utilizing ultrasound guidance, if used.
“The medical record must also include pre-treatment photographs of the varicose veins for which claims for
sclerotherapy are submitted to Medicare,” says NGS. “These photographs must be made available to the carrier upon
request for review.”
- Published on 2015-01-01
CPT © 2015 American Medical Association. All rights reserved.