General Surgery Coding Alert

Question: How should I code for an -excisional biopsy-? Is this a biopsy only, or is it truly an excision of some type?


Mississippi Subscriber

Answer: An -excisional biopsy- generally means a complete excision.

Your confusion is justified, however: Not only do physicians and coders apply the terms -excision- and -biopsy- imprecisely, but you can easily mistake a lesion excision for a biopsy because when your physician removes a lesion, he will usually also send a sample of the lesion for a biopsy afterward.

Quick tip: For coding, a biopsy (for example, 11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) refers only to removing part of the lesion for testing. An excision (for example, 11400-11646), in contrast, means that the surgeon removes the entire lesion.

Look for coding clues in the medical record to guide you. For instance, 11100 involves biopsy of skin, subcutaneous tissue and/or mucous membranes, plus simple closure. Typically, this just involves shaving the lesion, which may not require closure.
 
Even if your physicians simply mention biopsy in the record, you can tell if they excised the whole lesion by looking for details such as the number and type of sutures, the size and diameter of the lesion, how deep the incision went, and so on.

Watch out: Like -excisional biopsy,- a -punch biopsy- may also refer to removal of the whole lesion. An -incisional biopsy,- however, is a true biopsy that usually involves making an incision into the suspected cancer and removing a sample to confirm malignancy prior to excision.
 If you have any doubts about what the surgeon did, don't hesitate to ask.