General Surgery Coding Alert

One trick keeps multiple biopsy claims clean.

A year into the skin biopsy-code overhaul, readers ask certain recurring questions about how to use the codes. Read on to get our experts’ advice for flawless integumentary biopsy claims.

Emphasize Surgical Technique

Question 1: What distinguishes types of skin biopsies in a way that aligns with the CPT^® codes?

Answer 1: The integumentary biopsy section includes the following three codes 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))

Tip: Although the CPT^® guidelines characterize partial-thickness biopsies and full-thickness biopsies, that distinction isn’t what informs your code choice. Nor does specific anatomic skin site impact your code choice (with some exceptions you’ll read about in another FAQ). Instead, CPT^® identifies three specific techniques physicians can use to obtain skin biopsies: tangential, punch, and incisional. If your surgeon documents one of those standalone methods, you know the procedure is a biopsy.

Use the following brief guide to help you distinguishing the codes based on understanding the surgical technique:

Punch: In this procedure, “the surgeon pierces the lesion using a specialized skin biopsy instrument,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, National Director of Marketing and Revenue Management at FasPsych in Omaha, Nebr. The instrument is typically 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 removing 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 may involve a more complex closure.

Tangential: These codes describe taking a sample along the tangent, or superficially. The provider can accomplish this using the following techniques or instruments:

• 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.
• 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. Don’t confuse a shave biopsy with shaving procedures described by codes 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…), cautions Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. Codes 11300-11313 describe an excision procedure using a surgical blade with a horizontal slicing motion to remove the lesion from its base.

Distinguish Excision and Biopsy

Question 2: What’s the difference between an excision and a biopsy, and how does that impact coding?

Answer 2: Along with the codes 11102-+11107 introduced last year, CPT^® provides an updated guideline section that 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 is to obtain tissue solely for diagnostic histopathologic examination ….”

Excision: That’s different from an excision, which involves removing the entire lesion. CPT^® defines excision as “… removal of a lesion, including margins ….” If the surgeon performs a procedure intended to remove/excise the entire lesion, you should choose the appropriate CPT^® code based on the size and anatomic location of the lesion, and whether the lesion is malignant or benign. Report an excision of benign lesions using codes 11400-11446 (Excision, benign lesion …). A code from the 11600-11646 (Excision, malignant lesion including margins …) range describes malignant lesion excision.

Don’t miss: Excision isn’t the only procedure that you might confuse with skin biopsy. At the other extreme is a procedure that removes cells from the lesion surface. CPT^® guidelines state, “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.”

Look for Other Sites

Question 3: Does the skin biopsy section describe all skin biopsy procedures, or are there other, site-specific codes I should use in some circumstances?

Answer 3: Although codes 11102-+11107 describe most skin biopsy procedures, CPT^® does provide several site-specific codes you should know about. If your surgeon performs a skin biopsy from one of the following sites, you should report the more-specific code rather than a code from the integumentary biopsy section:

• 11755 (Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure))
• 30100 (Biopsy, intranasal)
• 40490 (Biopsy of lip)
• 40808 (Biopsy, vestibule of mouth)
• 41100, 41105 (Biopsy of tongue …)
• 41108 (Biopsy of floor of mouth)
• 54100 (Biopsy of penis; (separate procedure))
• 56605, 56606 (Biopsy of vulva or perineum (separate procedure) …)
• 67810 (Incisional biopsy of eyelid skin including lid margin)
• 68100 (Biopsy of conjunctiva)
• 69100 (Biopsy external ear)

Key: “Most of these codes pay more than the general integumentary biopsy codes because the procedures for these sites typically require more work,” says Joy. “In addition to misrepresenting your surgeon’s work, inadvertently missing the more-specific code could cost you significant pay.”

For example: A patient presents to your practice with a plaque-like lesion of the left lower eyelid. The surgeon makes an incision to biopsy the lesion. Because CPT^® provides a specific code, you should report 67810, which pays $185.14, instead of 11106, which pays $155.91 (national non-facility amount, conversion factor 36.0896).

Use This Add-On Tip

Question 4: How should I report multiple skin biopsies if the surgeon uses different surgical techniques for different lesions?

Answer 4: When the surgeon performs one skin lesion biopsy by one method, such as punch biopsy, and a second lesion biopsy using the same technique, most coders know to report the parent code for the first lesion (for example, 11104) and the related add-on code for each subsequent lesion (+11105).

But when the surgeon uses one technique for the first skin lesion biopsy (such as 11104) and a different technique for a second skin lesion biopsy, many coders have expressed uncertainty about how to code the case.

Do this: Report the parent code for the initial lesion based on biopsy technique. Then, report the add-on code — based on biopsy technique — for any second or subsequent skin biopsy.

For instance: Report a punch biopsy of a lesion of the left forearm as 11104, and a tangential biopsy of a distinct lesion of the right thigh on the same day as +11103.