Clinical Context
A 67-year-old male presents to a dermatology clinic with a biopsy-proven squamous cell carcinoma in situ on the forearm. The lesion measures approximately 0.8 cm in greatest diameter. After review of options, the treating dermatologist schedules office-based destruction using cryosurgery. The clinical workflow includes pre-procedure consent and site marking, local anesthesia if indicated, lesion destruction using cryotherapy probe with documented lesion size and technique, short observation for complications, wound care instructions, and documentation of diagnosis, procedure details, and follow-up for surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|
11 | Office or outpatient visit for evaluation and management | When an E/M service that meets criteria is performed and reported with the procedure (use per payer rules) |
22 | Increased procedural services | When the procedure requires substantially greater work than usual (must document rationale)
23 | Unusual anesthesia | When the procedure is performed under general or regional anesthesia unexpectedly (rare for this code)
52 | Reduced services | When the procedure is partially reduced or not completed (document extent)
53 | Discontinued procedure | When the procedure is terminated due to extenuating circumstances (document reason)
57 | Decision for surgery (not listed in raw modifiers) | Data not available in the input.
59 | Distinct procedural service | When another procedure or service not usually reported together is performed at a separate anatomical site or distinct encounter
76 | Repeat procedure by same physician | When the same physician repeats the procedure on the same day
77 | Repeat procedure by another physician | When a different physician repeats the procedure on the same day
LT | Left side | When the procedure is performed on the left-sided anatomic site
RT | Right side | When the procedure is performed on the right-sided anatomic site
50 | Bilateral procedure | When the procedure is performed bilaterally (when applicable by payer rules)
AQ | Ambulatory quality measures exemption | When the clinician is exempt from reporting certain quality measures (payer-specific)
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | When an advanced practice clinician assists at surgery (use per payer rules)
| Taxonomy Code | Specialty | Notes |
|---|
207Q00000X | Dermatology | Dermatologists commonly perform lesion destruction on trunk, arms, and legs |
207P00000X | Mohs and Dermatologic Surgery | Dermatologic surgeons perform excisions and destructive procedures for skin malignancies
207L00000X | Surgical Dermatology | Providers focused on surgical management of skin cancers perform office-based destructions
363A00000X | Family Medicine | Primary care physicians may perform minor skin procedures including destruction of small malignant lesions
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
C44.11 | Basal cell carcinoma of skin of eyelid, including canthus | Data not available in the input. |
C44.51 | Skin of trunk | Data not available in the input.
C44.611 | Malignant neoplasm of skin of right upper limb, including shoulder | Data not available in the input.
C44.612 | Malignant neoplasm of skin of left upper limb, including shoulder | Data not available in the input.
C44.619 | Malignant neoplasm of skin of unspecified upper limb | Data not available in the input.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
17000 | Destruction of premalignant lesion(s), up to 14 lesions | Used for actinic keratoses or premalignant lesions that may be treated in the same visit; different code set than malignant lesion destruction |
17260 | Destruction, malignant lesion, trunk, arms or legs; diameter 0.5 cm or less | Alternative code for smaller malignant lesions; select based on documented lesion diameter
17262 | Destruction, malignant lesion, trunk, arms or legs; diameter 1.1 cm to 2.0 cm | Used when lesion diameter exceeds the 17261 size range
11102 | Tangential biopsy of skin (shave), single lesion | Performed when diagnostic sampling is needed prior to definitive destruction
11400 | Excision of benign lesion including margins (size varies) | May be used when surgical excision rather than destructive technique is performed for a suspicious lesion
99213 | Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes | Common E/M level reported on the same day when a separate E/M is performed and supported by documentation