General Surgery Coding Alert

Question: How do I know when to report skin biopsy separately with, or in place of, other procedures such as shaving or excision?

California Subscriber

Answer: In general, you may report skin biopsy (11100-11101) separately when the biopsy occurs at a separate location from an excision or other removal, or when the results of the biopsy prompt the more extensive removal by excision or other method.

For instance, if the surgeon excises a lesion on the right hand and biopsies a different lesion (either on the right hand or elsewhere on the body), the excision and biopsy are separate. You should append modifier 59 (Distinct procedural service) to the biopsy code to show that it occurred at a different location from the excision.

Remember, however, that biopsy is a standard practice when removing skin lesions. In most cases, you would not report biopsy of the same lesion separately with an excision or other removal.

In an alternative scenario, the surgeon takes a biopsy by shave technique and submits the sample to pathology for examination. The results reveal a malignant lesion, which the surgeon then removes in its entirety, with margins, by excision.

In this case, the biopsy and excision are again separate because the biopsy led to the decision for the excision. When coding, you will want to append modifier 58 (Staged or related procedure or service by the same physician during the post-operative period) to the excision code to show that this was a staged procedure following the biopsy.

The surgeon's intent has a lot to do with distinguishing between a biopsy, for instance, and removal by shaving, excision, etc. The AMA has stressed this point, noting: "The intent of a biopsy is to remove a portion of skin, suspect lesion or entire lesion so that it can be examined pathologically" (CPT Assistant, Vol. 14, Issue 10: Oct. 2004). In contrast, "The intent of other integumentary system procedures that involve removal of tissue is different. Generally, they are performed for the purpose of removing the entire lesion."

Because physicians often use the terms "biopsy" and "excision" inter-changeably, you may find it useful to question your surgeon on those claims when the terminology and intent are unclear.

-- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.