General Surgery Coding Alert

When reporting shaving of epidermal or dermal lesions as described by 11300-11313, you must follow a very different set of rules than when you report more familiar lesion excision codes 11400-11646.

More fundamentally, you may not always be clear on when you should select 11300-11313 over the excision codes or, for that matter, a biopsy procedure. Here are the facts you need to discern and properly report shaving procedures.

To differentiate between shaving (11300-11313) and excision (11400-11646), you should consider first and foremost the depth of the removal.

Technically, anytime the surgeon removes skin tissue, an "excision" has occurred. But for coding purposes, CPT narrowly defines an excision as involving "full- thickness (through the dermis) removal of a lesion."

Shaving, by comparison, involves, "sharp removal ... without a full-thickness dermal excision." In some cases, the surgeon may remove the raised portion of a benign lesion and allow additional lesion tissue to persist in the dermis.

"Shaving implies a superficial removal," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop & Associates.

The surgeon's method to remove a lesion better reveals the difference between shaving and excision. During shaving, the surgeon uses a "transverse incision or horizontal slicing," as CPT notes, to remove the lesion. In this way, surgical shaving resembles shaving to remove body hair. For instance, the surgeon holds the blade horizontal to the skin and moves it across the lesion, literally shaving it off. Often, in fact, the surgeon will use a razor blade to shave a lesion.

Excision, in contrast, usually involves holding the blade perpendicular to (and thus cutting through) the skin to remove the lesion at a greater depth -- for which a scalpel is better suited. In these cases, the surgeon always wishes to remove the entire lesion to the greatest necessary depth.

"You have to read the documentation carefully," Bishop says. "Physicians may use terms like -shave biopsy- for a procedure CPT might describe as an excision."

Bottom line: Pay attention to the removal's depth more than the terminology your physician uses.

A final clue that may help you differentiate between shaving and excision is whether the surgical wound required repair, Bishop says. Although excision frequently requires suture or separate repair, shaving "does not require suture closure," CPT says.

You-ll see excisions more often: "General surgeons don't do a lot of shave removals," says M. Trayser Dunaway, MD, FACS, CSP, a general surgeon, author and educator with Healthcare Value in Camden, S.C. "We typically will completely excise all smallish lesions because we all get a bit nervous about spreading the tumor by a biopsy. When we excise, we may excise with close margins if we-re not sure [about the lesion's nature]. If necessary, we will return later to take wider margins."

When reporting shaving procedures, you must not consider the size of any margin the surgeon removes with the lesion. In fact, the surgeon may not document, or even take, a margin of tissue during a shave. This is a crucial difference from coding for excisions.

CPT groups shaving codes into three categories, as determined by the lesion's location:

- 11300-11303 -- trunk, arms or legs

- 11305-11308 -- scalp, neck, hands, feet, genitalia

- 11310-11313 -- face, ears, eyelids, nose, lips and mucous membrane.

Within each category, CPT further divides the codes by the lesion's size. Thus, 11301 applies for a lesion of the trunk, arms or legs measuring 0.6 cm to 1.0 cm, while 11302 applies to a lesion in any of the same locations but measuring 1.1 cm to 2.0 cm. Note once more that these measurements apply to the lesion's size only and does not include any margin.

The descriptors for 11300-11313 specify "single lesion," which means that you may report one code for each lesion that the surgeon shaves. If, for instance, the surgeon shaves 16 lesions, you may report an appropriate code for each. But if the surgeon shaves an extraordinary number of lesions during a single session, you may have to submit substantiating documentation.

For example, the surgeon removes by shaving four dermal lesions: one on the left upper arm, measuring 1.0 cm, two on the chest, measuring 1.4 cm and 1.6 cm, and another on the neck, measuring 0.4 cm. In this case, you would report 11301 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm) for the upper arm lesion, two units of 11302 (... lesion diameter 1.1 to 2.0 cm) to describe shaving of the chest lesions, and one unit of 11305 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less).

Bishop says that some payers might prefer that you list each removal as a separate line item, with modifier 59 (Distinct procedural service) appended to the second and subsequent codes. In the above example, for instance, this means you would report 11301, 11302, 11302-59 and 11305.

"This is payer-specific, so ask for instructions if you-re unsure," Bishop says.

CPT guidelines, reiterated by the AMA in CPT Assistant (Vol. 18, Issue 2; Feb. 2008), stipulate that removal of epidermal or dermal lesions using shave technique includes local anesthesia and, if necessary, chemical or electro cauterization to arrest bleeding. You should not attempt to code separately for these services.

Bishop says that the physician may choose freezing or chemical means to cauterize the wound, but as long as the physician doesn't place stitches or staples, the shave removal codes are still appropriate.

Although surgeons may submit samples taken using a shave technique for pathological examination, the results of the exam (whether benign, malignant or uncertain) have no bearing on your CPT coding (although, obviously they matter tremendously for ICD-9 coding). Again, this is in contrast to excisions, which designate separate code ranges for benign and malignant lesions.

Perhaps more important, however, you must be careful not to confuse removal by shaving with biopsy only as described by 11100-11101. In fact, CPT instructions preceding the biopsy codes specifically site "shave removals" as a method to obtain tissue for pathologic examination, which has added to the confusion over how to differentiate 11300-11313 from 11100-11101.

In the end, physician intent matters most, Dunaway says. Often, a surgeon will remove by shaving a lesion that she suspects is benign. Although she may submit the tissue for biopsy, you should still select an appropriate shaving code rather than the biopsy code (biopsy is included in the shave).

In the case of a suspected malignant lesion, however, the surgeon may use shaving to remove a portion of the tissue for examination, with the intent of removing the entire lesion by excision if pathology confirms malignancy. In such a case, you would apply the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and, if required at a later session, the appropriate code for excision of malignant lesion procedure (11600-11646).

But even if the pathology report did not reveal malignancy in the above case, you would still report the biopsy code rather than a code for removal by shaving. In this case, the intent was to obtain sample tissue for examination, not removal.

For more information on when to report biopsy separately, see Reader Question "Consider Timing, Location, Intent for Skin Biopsy" on page 71 this issue.