General Surgery Coding Alert

Technique documentation leads code choice.

Almost nothing is left of the skin-biopsy section in CPT^® 2019, so get ready to learn a whole new set of codes and rules.

Let our experts’ advice guide you to error-free, iron-clad claims when your general surgeons perform skin biopsies this year.

Tip 1: Throw Out the Old Codes

CPT^® 2019 deletes the two skin biopsy 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)).

“Codes 11100 and +11101 have been under scrutiny by CMS for some time for being used in inconsistent ways,” says Christine Marcelli, CPC, CPPM, CSFAC, practice manager with a clinic in Canton, Ohio.

The lack of clarity in the 11100 code family stems from the fact that surgeons use a range of biopsy techniques, but the codes don’t reflect those procedural differences.

“The skin biopsy codes have always been a bit unclear in that regard, because they always seemed to me to imply a punch biopsy,” reasons Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “But a punch is also often used to completely excise a small suspicious lesion,” Bucknam adds, noting that this led to confusion over the procedure’s purpose.

Additionally, “the deleted codes were very broad and would require submitting medical records to justify the various techniques used for a certain type of biopsy,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas.

Tip 2: Bring in the New Codes

CPT^® 2019 introduces the following six new codes — three that describe removing a single lesion with different, specific techniques, and three add-on codes for removal of multiple lesions:

• 11102 (Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion)
• +11103 (… each separate/additional lesion (List separately in addition to code for primary procedure))
• 11104 (Punch biopsy of skin (including simple closure, when performed); single lesion)
• +11105 (… each separate/additional lesion (List separately in addition to code for primary procedure))
• 11106 (Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion)
• +11107 (… each separate/additional lesion (List separately in addition to code for primary procedure)).

Guidance: Because the distinguishing the new codes depends on understanding the surgical technique, use the following brief guide so you can quickly and accurately report these codes using your surgeons’ documentation.

Tangential: As the descriptor for 11102/+11103 implies, you can use these codes when your provider takes a sample along the tangent, or the sample is superficial, according to Charles. The provider can accomplish this using the following techniques or instruments:

• Shave, which means removing a tissue sample by elevating the skin, then using a straight blade to slice the skin to the epidermis or superficial dermis level.
• Scoop, which requires going deeper than shaving and uses a straight or flexible blade.
• Saucerization, which is like a scoop but doesn’t go as deep and uses a razor that is folded. This technique is mostly used for lesions that may be melanomas.
• Curette, which can either refer to the instrument used in a scoop biopsy or to a curettage biopsy, which is a seldom-used technique to biopsy a difficult-to-reach anatomic area.

Punch: In this procedure, “the patient is anaesthetized and pierced, typically using a disposable skin biopsy instrument” says Charles. The instrument is usually a 2-8 mm pen that can go deep into the subcutaneous layer and remove a full-thickness, cylindrical sample of skin.

Incisional: This biopsy involves removal of a larger and deeper amount of skin — a full-thickness sample of tissue penetrating deep to the dermis, into the subcutaneous space — which typically requires the use of a scalpel and involves a more complex closure, explains Charles.

Bottom line: Many in the industry welcome the CPT^® 2019 skin-biopsy changes. “The new codes will allow more specific pricing and will make it clearer what was done,” says Bucknam.

Tip 3: Make Sure It’s a Biopsy

With an all-new guidelines section, CPT^® 2019 has lots to say to help you distinguish skin biopsies from other skin procedures, such as excisions or scrapings.

Purpose: According to CPT^® guidelines, biopsies “sample” a lesion, and codes 11102 through +11107 “indicate that the procedure to obtain tissue solely for diagnostic histopathologic examination ….” That’s different from an excision, which involves removing the entire lesion (CPT^® defines excision as “… removal of a lesion, including margins …”).

At the other extreme, “sampling of stratum corneum only, by any modality (eg, skin scraping, tape stripping) does not constitute a skin biopsy procedure and is not separately reportable,” according to CPT^® guidelines.

Bottom line: Although the guidelines go on to characterize partial-thickness biopsies and full-thickness biopsies, that distinction isn’t what informs your code choice. Instead, CPT^® identifies three specific techniques physicians can use to obtain skin biopsies: tangential, punch, and incisional. If your surgeon documents one of those stand-alone methods, you know the procedure is a biopsy.

Tip 4: Know Whether You Can Separately Report Biopsy

You just learned that a biopsy obtains tissue only for only pathological diagnosis, but the guidelines go on to clarify that the procedure must be “performed independently or [be] unrelated or distinct from other procedures/services provided at that time.”

The guidelines state, “During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. … This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported.”

Do separately report: You may separately report biopsies the surgeon performs on different lesions or different sites on the same date of service, because they are not considered components of other procedures, per CPT^® guidelines. In those cases, you should select an add-on code to report additional lesion biopsies taken on the same date of service as the initial biopsy.