Look to 11102 for a Shave Biopsy
Question: A new patient with a lesion on their lip presented to a dermatologist’s office. The dermatologist examined the patient’s lip and performed a shave biopsy of the lesion. What code should I report for the biopsy? Pennsylvania Subscriber Answer: Assign 11102 (Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion) to report the shave biopsy of the lesion on the patient’s lip. This is known as a tangential biopsy, which means the physician used a sharp blade to collect a sample of the epidermal tissue. The sample is then examined to determine the pathology. The descriptor for 11102 provides examples of the methods used to collect the specimen. Some coders may be inclined to use 40490 (Biopsy of lip) to report this procedure, but that is incorrect. Code 40490 is the wrong choice because in order to report 40490, the physician must incise the lip to collect a full-thickness sample of the lesion, which includes the dermis and subcutaneous space. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
