# based on this sample chart....



## TSmith9672 (Jul 3, 2013)

hello all, I am new to derm coding and am very confused on the correct code for shave bx and punch bx. If I am correct the technique does not influence code selection but rather the size and location...??? when I look up shave bx and punch bx it yields the same code(s) 11100 and 11101 for each additional lesion. Would anyone be so kind to take a look at the sample procedure note(below)and explain/break down how I can determine the best code selection and the documentation required to support shave bx and punch bx. Thanks in advance!

female
Here for a skin check. No new or changing moles today other than two mentioned below, melanoma scar looks and feels fine on L thigh.
Moles all over. On R thigh one is darkening (midline thigh, called medial) and one is changing shape (lateral thigh).


Review of Systems:
-no fevers, chills, weight loss, cough, headaches, shortness of breath, or lumps under skin


Past Medical, Family, and Social history:
-married, has two sons, 4 grandchildren (3 from son's wife's prior marriage)
-melanoma, see above
-fell off toilet in March (vagal episode) but doing fine


Exam:
-general: alert, well nourished
-skin:
Fitz 1
-R medial thigh hyperpigmented macule with jagged edge, R lateral thigh hyperpigmented macule adjacent to tan patch (lentigo v SK adjacent to nevus)
-back tan to brown waxy stuck on papule(s) consistent with seborrheic keratosis(es)
-back, arms, legs, chest hyperpigmented macules and papules and some skin colored papules consistent with benign nevi
-no palpable lymphadenopathy in neck, axillae or inguinal creases
-face, scalp, ears, neck, chest, abdomen, arms, legs, back, buttocks, groin clear other than above lesions


Assessment and Plan:
1.  HX OF MELANOMA OF SKIN   MELAN FOLLOW-UP COMPLETE Total body skin exam done 
No new or changing moles
ABCDEs discussed

2.  NEVI/MOLES.     
3.  SEBORRHEIC KERATOSIS   2,3: Lesions appear benign, reassured patient. Asked patient to report any change in the lesions so they can be reevaluated promptly. 

4.  NEOPLASM OF UNCERTAIN BEHAVIOR, SKIN   
R medial thigh
R lateral thigh  BIOPSY OF SKIN, EACH ADDITIONAL LESION, BIOPSY, SHAVE, HISTOPATHOLOGY TISSUE, BIOPSY  

See patient instructions section of after visit summary for further details.


Procedure note for skin biopsy of area noted above           


PREOPERATIVE
Procedure explained including options and risks.
Briefing/verification utilized: yes
Time-out utilized: yes


OPERATIVE
Area prepped with EtOH
Local anesthetic: lidocaine 2% with epinephrine
Biopsy performed, shave technique, entire visible lesion removed at each site x 2.  
Hemostasis: electrodesiccation


POSTOPERATIVE
-Patient tolerated the procedure well.
-Wound dressed with petrolatum ointment and bandage, specimen sent to Dermatopathology.   
-Verbal and written wound care instructions given and patient verbalizes understanding.
-Pathology: Patient will be notified by mail or phone and appropriate follow up will be arranged if needed.
-Patient was asked to call if no results by mail, email or phone within 3 weeks, since we will notify all patients whether benign or malignant


----------



## mitchellde (Jul 3, 2013)

so the first thing is you cannot use the dx code for neoplasm of uncertain behavior(238.-) until you have a path report that states it is of uncertain behavior.  Those codes do not indicate physician uncertainty as to what the path will be.  Therefore you can use the 709.8 code and these are shaving removal codes, a biospy is to remove only a piece of a lesion either full or partial thickness and a shave is to remove the entire visible anomaly to a depth of partial thickness.  You need a better procedure note as we do need to know if this was partial thickness of full thickness and size.


----------



## dermatologytech (Jul 3, 2013)

mitchellde said:


> so the first thing is you cannot use the dx code for neoplasm of uncertain behavior(238.-) until you have a path report that states it is of uncertain behavior.



I realize that there are regional differences and provider preferences, but I've used 238.2 with biopsies for _years_.  If anything, it's because of the uncertainty of the diagnosis that 238.2 is appropriate.  Only if the charges are withheld until path confirms the diagnosis would a more specific diagnosis be appropriate.  I'd actually say that most providers I know use 238.2 as their default biopsy code.  

With regard to the coding and documentation, the note suggests biopsy only, and not shave removal.  The difference is the _intention_.  If the provider is intending to simply sample the lesion, then he/she would use the term shave _biopsy _(which they've done).  Shave _removal _would be the chosen wording if their intention was to provide definitive removal, regardless of the actual depth that was obtained. 

Also, and one thing I'd have to critique the doc's note about, is that there are no lesion sizes indicated.  Maybe they're in the original note?  Shave removal codes are dependent on size, whereas biopsy codes are not.  Proper documentation should indicate lesion size either way.  But the fact that no size is documented, along with the "biopsy" wording, essentially prevents you from documenting shave removal anyway.


----------



## mitchellde (Jul 3, 2013)

Your interpretation of the 238 dx codes is incorrect.  Even though you have done it that way for years and been paid, it is still very incorrect.  The dx is the patient's not yours and they depend on you to be correct.  Look in your code book at the definition at the sub chapter heading for neoplasm of uncertain behavior.  You cannot change the meaning of the diagnosis codes.
Also the note states he shaved the entire visible lesion.  You cannot code a shave removal as a biopsy, and to remove the entire visible lesion is not a biopsy.


----------



## TSmith9672 (Jul 4, 2013)

mitchellde said:


> Your interpretation of the 238 dx codes is incorrect.  Even though you have done it that way for years and been paid, it is still very incorrect.  The dx is the patient's not yours and they depend on you to be correct.  Look in your code book at the definition at the sub chapter heading for neoplasm of uncertain behavior.  You cannot change the meaning of the diagnosis codes.
> Also the note states he shaved the entire visible lesion.  You cannot code a shave removal as a biopsy, and to remove the entire visible lesion is not a biopsy.



Thanks for yor guidance, but if the docementation doesn't support a bx, then what px code does it support and how would  determine that based on this report. I am clear that dx code 238 is supported by path report but very fuzzy on px codes in this instance. Basically, what are the correct code  selection for bx of lesion and shave bx of a lesion? What should i look for in the documentation to support and/ or differientiate these codes,( i.e., lesion size, instrument, method, etc..) Thanks again, i really appreciate it


----------



## TSmith9672 (Jul 4, 2013)

mitchellde said:


> so the first thing is you cannot use the dx code for neoplasm of uncertain behavior(238.-) until you have a path report that states it is of uncertain behavior.  Those codes do not indicate physician uncertainty as to what the path will be.  Therefore you can use the 709.8 code and these are shaving removal codes, a biospy is to remove only a piece of a lesion either full or partial thickness and a shave is to remove the entire visible anomaly to a depth of partial thickness.  You need a better procedure note as we do need to know if this was partial thickness of full thickness and size.



Ok, i think this clears up how to determine which px code and that ilthe selection is based on to  the exent of removal, correct?


----------



## mitchellde (Jul 4, 2013)

Yes that is correct


----------



## dermatologytech (Jul 7, 2013)

mitchellde said:


> Your interpretation of the 238 dx codes is incorrect.



I respectfully disagree and would encourage the original poster to seek other opinions.  

The original intention may have been to reflect a _pathology _diagnosis, but over the years it's become accepted as the most appropriate way of classifying skin lesions for which no diagnosis is yet available.  In other words, neoplasms which are _clinically _"of uncertain behavior".  

This opinion is not my own.  I can assure you that 238.2 is* the most common* ICD paired with the skin biopsy codes throughout the country.  

For other opinions on the matter, see the following...

http://www.the-dermatologist.com/article/399

http://www.supercoder.com/my-ask-an-expert/topic/cpt-11100-with-dx-2382



mitchellde said:


> ...to remove the entire visible lesion is not a biopsy.



Again, I respectfully disagree.  It completely depends on the lesion.  

Let's say a patient has a suspected melanoma, and path confirms that suspicion in the following days.  I can shave off the "entire visible lesion" and submit it to pathology.  Even though the lesion is no longer visible, I shouldn't say that "shave removal" was performed, because once path confirms the melanoma diagnosis, complete excision of the location w/ appropriate margins is then necessary.  Instead, the original "shaving of the entire visible lesion" only served the purpose of determining the diagnosis and should be coded as a "biopsy".  The term "removal" should only be used when treatment is considered _definitive_.

In this visit, these lesions are being tested to r/o atypia in a patient with a h/o melanoma.  When clinicians test such lesions, they are aware that a pathology result showing atypia is a very real possibility.  If significant atypia is confirmed, the standard of care is to then excise with appropriate margins, because shave removal without margins isn't sufficient.  If the dermatologist were to call this procedure a "removal", without yet knowing the path, then that opens the possibility that the same lesion will be coded as being removed _twice_ (initially by "shave removal" and later by "excision"), which, as stated, is inappropriate.  This is the reason that most dermatologists will code all suspicious lesions as a "biopsy" (until and unless proven otherwise by pathology) and reserve the "shave removal" codes for those lesions which clearly present in a benign fashion.  

Secondly, the term "biopsy" is used in the note itself.  That clearly indicates the providers intention.  He or she is ultimately responsible for the submitted charges, and it would be inappropriate to override the provider's clearly-stated intention.

There is an exception in which shave removal can be charged for this visit, though, and that is if pathology confirms that the lesions are in fact benign.  Removing "all of the visible lesion" *is  *accepted as definitive treatment _of benign lesions only_ - not those with significant atypia and certainly not for skin cancer.  So in the end, it depends on when the charges are submitted - before path confirmation or after?

I certainly don't intend to confuse the original poster with our two very different responses.  But it's an important topic for someone new to dermatology coding, and a scenario which occurs regularly.  I would encourage other dermatology-experienced coders to provide input as well.


----------



## mitchellde (Jul 7, 2013)

sorry to correct you , but the definition of the ICD-9/ICD-10 codes is determined by the WHO and The NCHS, not by popular definition.  These codes can only be used with pathology results that indicate the cells cannot be determined to be benign or malignant.  Please read the ICD-9/ICD-10 Book to confirm this, these codes reflect only a path diagnosis.
The definition of a biopsy vs a shave vs an excision is determined by the AMA that created the codes, this was defined by depth and amount of removal in a CPT assistant many years ago.  
I have coded neoplasm and derm for many years.  the depth of removal is not determined by path it is determined by provider description.  Just saying biopsy does not make it a biopsy.  There are very strict rules in this industry and strict definitions, these cannot be twisted for individual use.  
To determine the true definition of a code or procedure it is always best to rely on those parties that created the codes.  The definition in the ICD code books will over ride anything that has "always been done that way".


----------



## dermatologytech (Jul 9, 2013)

mitchellde said:


> The definition of a biopsy vs a shave vs an excision is determined by the AMA that created the codes, this was defined by depth and amount of removal in a CPT assistant many years ago.



Biopsy codes *are not* defined by depth and amount of removal.  For biopsies, it's all about _intent_, regardless of how much tissue is removed.

From the October 2004 CPT Assistant...

_“The intent of a biopsy is to remove a portion of skin, suspect lesion, *or entire lesion* so that it can be examined pathologically.”_

Another good article regarding shaves vs. biopsies can be found here.  It was written by a member of the AAD's AMA-CPT advisory committee:

http://www.aad.org/dw/monthly/2013/april/biopsy-shave-or-excision#allpages

Both lesions in question were changing in a patient with a history of melanoma.  The intention of performing the procedures is clearly to r/o atypia.  All requirements for biopsy have been met and the physician uses the wording of "biopsy".  To say that he (or she) doesn't understand the significance of such wording would be irresponsible.


----------



## mitchellde (Jul 9, 2013)

many do not understand the wording , there are several that feel sending a specimen to path is a biopsy but it is not, If the provider removes the entire visible anomaly but feels there is more that cannot be obtained in this session and sends the tissues obtained to path then that is a biopsy.  If the entire lesion is removed and the provider feels this is the entire anomaly , then it depends on depth as to whether it is a shave or an excision.   I am sorry we disagree, but clearly we do.  Regardless of how you feel about the procedure codes, the diagnosis cannot be a 238 without a path report.


----------



## TSmith9672 (Jul 14, 2013)

*Thank you*

Thank you both for your clarifications, I truly appreciate it. I am not further confused, this just proves that coding is subjective. Code selection is primarily based on the interpretation of the providers documentation. This is why there are supportive resources to research questionable code definition. Also, thank you dermatologytech for the links you provided.


----------

