General Surgery Coding Alert

Question: My I report a biopsy code in addition to an excision at the same location? Or is the biopsy included?

New York Subscriber

Answer: In most cases, you would not report a biopsy (e.g., 11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) at the same time as a more extensive procedure (such as excision, destruction or removal) at the same location. A follow-up biopsy is an integral component of an excision, for example, and necessary to identify the type of lesion (benign, malignant, etc.) for appropriate CPT and ICD-9 coding.

National Correct Coding Initiative (CCI) guidelines support this advice, explaining, "If a biopsy is obtained for evaluation after the procedure is completed, the biopsy is not separately reportable with an excision, removal, destruction, fulguration, or other elimination procedure of the biopsied lesion."

When the biopsy precedes and leads to the excision, however, you may report the biopsy separately. For instance, the surgeon biopsies a breast lesion and finds malignancy, then follows up with an excision (e.g., 11603, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm). CCI guidelines specify, "If the biopsy is performed on the same lesion on which the more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the result of the pathologic examination."

In other words: If the biopsy precedes the excision, you can likely report both procedures. But if the excision precedes the biopsy, you can report only the excision.

When you do report a biopsy and excision of the same location separately, be sure to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the biopsy code to indicate that the biopsy prompted the excision.

Of course, if the surgeon biopsies and excises different lesions, you may report the procedures independently. Just be sure to append modifier 59 (Distinct procedural service) to the biopsy code to show that it occurred at a separate anatomical location from the excision.