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Dermatology Coding Alert

CPT 2004 Update:

3 Tips to Recoup Biopsy and Excision Pay

Published on Thu Jan 01, 2004

Good news, dermatology coders: CPT 2004 clarifies guidelines to help you determine when you can report a biopsy code and when tissue removal is included in another procedure.
 
These new biopsy guidelines, which go into effect Ja n. 1, refer to codes 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and +11101 (... each separate/additional lesion [list separately in addition to code for primary procedure]). CPT's new instructional notes clarify that you shouldn't report 11100 and 11101 with other excision and biopsy codes on the same lesion because the biopsy is a routine component of such procedures, advise coding experts.
 
The intent of the new guidelines is to provide guidance to coders to code correctly, as well as to third party payers who may have denied the biopsy of a separate site or session, instead of paying for the service, explains Linda Howrey, BS, CCS-P, of Howrey and Associates in Princeton, Mass.
 
The guidelines indicate that:

 

  • You should not report 11100 and 11101 when you bill for another procedure, such as an excision (11400, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less). Specifically, when dermatologists obtain tissue for pathology during excision, destruction or shave removals, this biopsy is bundled to the primary procedure, so you may not report the biopsy separately. For instance, if the physician removes an entire lesion and submits it to pathology, you should use only 11400. You shouldn't use a biopsy code because CPT considers the biopsy a component of 11400, according to the new guidelines and current National Correct Coding Initiative (NCCI) edits.

     

  • You should report 11100 and 11101 only when the physician obtains a specimen. For example, your dermatologist removes a portion of a patient's skin lesion and sends the specimen to pathology. No additional work, such as shaving or removal of the remainder of the lesion, is performed. In that case, you would use 11100. You should assign add-on code 11101 in addition to 11100 when the physician takes a biopsy of another lesion.

     

  • When the physician performs a biopsy on a different site from the excision, you may separately assign 11100 and 11101. For instance, your dermatologist excises an entire benign lesion from a patient's arm and a portion of a lesion on the same patient's neck. For the arm lesion, use 11400, and for the neck biopsy, list 11100.  
     Make sure you link the respective diagnoses to the proper procedure code.
     
    Use Modifier -59 To Unbundle

    If you end up reporting a biopsy procedure that is separate from your other procedure, you may need to append modifier -59 (Distinct procedural service) to be reimbursed. "In theory, this should not require a modifier, but most insurers will probably still bundle these codes, and you may still have to apply modifier -59 to get reimbursement," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.
     
    For instance, if the dermatologist removes a lesion from the left arm (11401, ... excised diameter 0.6 to 1.0 cm) and takes a biopsy from a different lesion on the same arm, CPT now considers the biopsy separate from the excision.
     
    You therefore could report the biopsy as one procedure (11401) and the excision as another (11100-59), but check with your payer first.
     
    Note: Refer to the AMA's CPT Changes 2004: An Insider's View for more details regarding these changes.

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