# punch/incisional biopsy with closure



## ashleydbeck1 (Feb 8, 2019)

My provider has documented that she did a punch biopsy with a layered (intermediate) closure.  The CPT book states that simple closures are included in a punch biopsy but I have not been able to find any information on if intermediate or complex closures are separately billable with a punch or incisional biopsy.  I am saying yes, they are but my manager is saying she doesn't think they are separately billable.  Does anyone have any information on this?

Thanks!


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## csperoni (Feb 8, 2019)

*Check CCI edits*

It looks like intermediate closures are a column 2 CCI edit with both punch biopsy 11104 and incisional biopsy 11106.  Column 2 means (if justified), a -59 modifier will override the edit.  In this situation, -59 is not justified as it is most definitely a related procedure.  It does seem odd to me the description only specifies simple closure.  This may be one of those situations where AMA has 1 opinion, but CMS has another.


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## JesseL (Feb 8, 2019)

If the result of the procedure needed a layered closure, would that mean it was more of an excision that involved deeper skin layers than it was a simple biopsy? That is if what was biopsied was a lesion?


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## csperoni (Feb 8, 2019)

Regardless of depth, a biopsy is definitely different than an excision.  A biopsy is sampling a portion, not removing the lesion.  
Here is some additional information from Supercoder (edited for length/relevance to this question).  It does not address separate billing for intermediate closure, which was why I then referenced CCI.  I personally may not agree with the CCI edit, but would follow their rules.

 Partial-thickness biopsies are those that sample a portion of the thickness of skin or mucous membrane and do not penetrate below the dermis or lamina propria. Full-thickness biopsies penetrate into tissue deep to the dermis or lamina propria, into the subcutaneous or submucosal space. 

  An appropriate biopsy technique is selected based on optimal tissue-sampling considerations for the type of neoplastic, inflammatory, or other lesion requiring a tissue diagnosis. Biopsy of the skin is reported under three distinct techniques: 
* Tangential biopsy (eg, shave, scoop, saucerize, curette) is performed with a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel or curette to remove a sample of epidermal tissue with or without portions of underlying dermis. The intent of a tangential biopsy (11102, 11103) is to obtain a tissue sample from a lesion for the purpose of diagnostic pathologic examination. Biopsy of lesions by tangential technique (11102, 11103) is not considered an excision. Tangential biopsy technique may be represented by a superficial sample and does not involve the full thickness of the dermis, which could result in portions of the lesion remaining in the deeper layers of the dermis. 
* Punch biopsy requires a punch tool to remove a full-thickness cylindrical sample of skin. The intent of a punch biopsy (11104, 11105) is to obtain a cylindrical tissue sample of a cutaneous lesion for the purpose of diagnostic pathologic examination. Simple closure of the defect is included in the service. Manipulation of the biopsy defect to improve wound approximation is included in simple closure. 
* Incisional biopsy requires the use of a sharp blade (not a punch tool) to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating deep to the dermis, into the subcutaneous space. The intent of an incisional biopsy (11106, 11107) is to obtain a full-thickness tissue sample of a skin lesion for the purpose of diagnostic pathologic examination. This type of biopsy may sample subcutaneous fat, such as those performed for the evaluation of panniculitis. Although closure is usually performed on incisional biopsies, simple closure is not separately reported. 

 (For complete lesion excision with margins, see 11400-11646) 

 When multiple biopsy techniques are performed during the same encounter, only one primary lesion biopsy code (11102, 11104, 11106) is reported. Additional biopsy codes should be selected based on the following convention: 
- If multiple biopsies of the same type are performed, the primary code for that biopsy should be used along with the corresponding add-on code(s). 
- If an incisional biopsy is performed, report 11106 in combination with a tangential (11103), punch (11105), or incisional biopsy (11107) for the additional biopsy procedures. 
- If a punch biopsy is performed, report 11104 in combination with a tangential (11103), or punch (11105), for the additional biopsy procedures. 
- If multiple tangential biopsies are performed, report tangential biopsy (11102) in combination with 11103 for the additional tangential biopsy procedures. 
- When two or more biopsies of the same technique (ie, tangential, punch, or incisional) are performed on separate/additional lesions, use the appropriate add-on code (11103, 11105, 11107) to specify each additional biopsy. When two or three different biopsy techniques (ie, tangential, punch, or incisional) are performed to sample separate/additional lesions, select the appropriate biopsy code (11102, 11104, 11106) plus an additional add-on code (11103, 11105, 11107) for each additional biopsy performed.


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## CodingKing (Feb 9, 2019)

NCCI didn't allow separate reporting closure with the old biopsy code so i'm not surprised they still bundle it with the new codes. How the procedure is performed has not change with the new codes. The old codes were considered to be misvalued and AMA decided to break them up to tie reimbursement to the complexity of obtaining the sample. 

http://bulletin.facs.org/2019/01/2019-cpt-coding-changes/

Perhaps Incisional was an error since the codes description says includes simple?

There is a process to appeal decisions by NCCI:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html



> If the viewer has concerns about specific NCCI edits, he/she may submit comments in writing to:
> National Correct Coding Initiative
> Correct Coding Solutions LLC
> P.O. Box 907
> ...



It might be worth appealing to the payers as well as many can customize the edit to override NCCI


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