General Surgery Coding Alert

Look for site-specific codes.

If you think 11100-+11101 are the only codes that describe skin biopsy procedures, think again.

In fact, CPT^® provides many codes that describe skin biopsies from specific sites, and other codes that describe skin removal procedures that aren’t quite biopsies. Read on to learn the difference, and make sure you get all the pay you deserve for your surgeon’s integumentary lesion procedures.

Follow ‘Otherwise Listed’ Instruction

When you look at the following code definitions, you should see the clear hint that these aren’t the only skin biopsy codes to choose from:

• 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion).
• +11101 (…each separate/additional lesion (List separately in addition to code for primary procedure)).

Because the 11100 code definition states “unless otherwise listed,” you should not use 11100 if the skin biopsy was taken from a specific site listed elsewhere in CPT^®.

Rule: Any time there is a code that describes the specific site of the biopsy, report the more specific biopsy code. “The location of each biopsy should be clearly supported by documentation,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner of Pinnacle Enterprise Risk Consulting Services, LLC. “Often, the physician will draw a picture of the location in the handwritten notes. In EMR, this can be a challenge, so a clear verbal description should be evident.”

Benefit: The more specific code allows greater reimbursement for the higher level of complexity for site-specific procedures. Your surgery practice stands to lose significant income if your code choices don’t reflect these site-specific codes. See “Sacrifice Up To $97 per Lesion for 11100 Misuse” on page 59 to identify some explicit codes at your disposal for reporting biopsies of site-specific skin lesions.

Example: A patient presents to your practice with a papular lesion of the lip. The surgeon performs a biopsy. Assuming adequate documentation of the site, you should code the case as 40490 (Biopsy of lip) instead of 11100. Code 40490 pays $132.48 on the 2018 Medicare Physician Fee Schedule (MPFS), which is $24.48 more than the payment for 11100 ($108) based on national non-facility amount, conversion factor $35.9996. The extra pay reflects the extra work involved in lip biopsy, such as use of a chalazion clamp to control bleeding.

Classify Excision vs. Biopsy

When the surgeon intends to fully remove a lesion, he performs an excision. If the surgeon’s goal is just to take a sample of the lesion for diagnosis, he performs a biopsy, typically leaving part of the lesion intact.

Pitfall: “Some surgeons use the confusing language ‘excisional biopsy’ in their op reports,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr. You may need to get further clarification from the surgeon to determine if the procedure was a biopsy or an excision before you can assign the appropriate code.

If the surgeon removes the entire skin lesion, attempting to have clear margins, you should choose an excision CPT® code based on the lesion location, size, and behavior (malignant or benign).

Report the excision of a benign lesion with the appropriate code from the range 11400-11446 (Excision, benign lesion …). For instance, you might list 11421 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm).

For excision of a malignant lesion, assign a code from the range 11600-11646 (Excision, malignant lesion …), such as 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less).

Pathology report: Although the pathology report won’t change the biopsy code you list, it could change the excision code you choose, “for example, if you think a benign lesion was excised but the path report came back malignant,” explains Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. The pathology report will also help determine the diagnosis (ICD-10-CM) code, so for a complete, accurate claim, it is wise to wait for the pathology determination, Biffle advises.

Distinguish Shave Removal

Shave removals are also a common source of coding confusion, according to Biffle. These procedures are not a biopsy removed for diagnosis, or an excision to detach an entire lesion with clear margins, but a surgery to shave off at least a raised part of a lesion, and possibly the entire lesion. Shaving involves sharp removal without full-thickness dermal excision. That means you should not use the biopsy or excision codes to report these procedures.

Do this: If your surgeon performs a “shave removal,” you should turn to 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…). These codes are site and size dependent, such as 11302 (… trunk, arms or legs; lesion diameter 1.1 to 2.0 cm).

Document carefully: Surgeons sometimes refer to a shave removal as a “shave biopsy” or “shave excision,” which can be confusing. You should check the details of the op report for evidence of thickness, margins, or other details. “Another clue is that there is never closure with a shave removal, but there might be cautery of the wound bed,” advises Joy. Use these details from the op report to ensure that you’re coding the proper procedure.