General Surgery Coding Alert

Question: Can we report a biopsy and excision of the same lesion during the same session?

North Dakota Subscriber

Answer: Instructional notes added to CPT in 2004 clarify that you shouldn't report 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]) in addition to excision or other biopsy codes unless certain exceptions exist (as outlined below).

Notes preceding CPT's -Biopsy- portion instruct:

Report 11100 and 11101 only when the physician obtains a specimen. For example, the surgeon removes a portion of a patient's skin lesion (709.1, Vascular disorders of skin) and sends the specimen to pathology. In that case, you would use 11100. You should assign add-on code 11101 along with 11100 when the surgeon takes a biopsy of a second lesion. You may report one additional unit of 11101 for each additional biopsy the surgeon takes.

You can't report 11100 and 11101 when you bill for another procedure, such as an excision. For instance, if the surgeon removes an entire lesion and submits it to pathology, you should use only 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less). You shouldn't use a biopsy code because CPT considers the biopsy a component of 11400.

Exception 1: If your surgeon bases her decision to perform the excision on the biopsy's results, you may report both services with modifier 59 (Distinct procedural service) on the biopsy code(s) (11100 and 11101). This would be appropriate when, for example, the physician would not remove the lesion due to its location unless the results are malignant. If the surgeon performs the biopsy simply to verify that the lesion requires removal, the excision includes the biopsy.

Exception 2: When the surgeon performs a biopsy on a different site from the excision, you may separately assign 11100 and 11101. For example, your surgeon removes an entire benign lesion from a patient's arm and biopsies a lesion on a patient's neck. For the arm lesion, use 11400. For the neck biopsy report 11100-59. By appending modifier 59 to the second code, you indicate that the biopsy occurred at a separate location from the lesion removal.