Internal Medicine Coding Alert

 Test yourself on everyday biopsy and excision dilemmas

Even though your internist documented a "punch biopsy," you should not rule out coding the procedure as an excision. The best ways for distinguishing between the two are investigating the lesion's size, depth and margins, and determining why the physician performed the procedure.
 
Report Excision for Removing Entire Lesion

If your internist removes part of a lesion, you should assign a biopsy code, says Pamela J. Biffle, CPC,  CCS-P, an independent consultant in the Dallas/Fort Worth area. For a complete removal, you should use an excision code.
 
Example #1: A patient presents with a raised, suspicious-appearing 2-mm lesion on her upper-right cheek. The internist completely removes the lesion using a 3-mm punch excisional tool through the dermis and closes the surgery site with one 4-0 ethilon suture.
 
Coding: In this case, the internist removed the entire lesion. You should therefore report the excision code (11440, Excision, other benign lesion including margins [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less; or 11640, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less) depending on the pathology report. If the report shows a benign lesion, use 11440. For a malignant lesion, submit 11640.
 
Be careful: Excision includes simple closure, "So don't separately report the suture," Biffle says.

Code Full-Thickness Removal as Excision

What if your internist fails to document whether he removed part or all of a lesion? You should determine the lesion removal depth. CPT defines an excision as a full-thickness (through the dermis) removal.
 
Example #2: A patient presents to your office with a dark brown, multicolored, irregular-shaped 3-mm lesion on his neck. The physician uses a 4-mm punch excision tool to remove the lesion to full thickness. She then closes the site with two 4-0 ethilon sutures in a simple interrupted fashion.
 
Answer: You should bill a lesion excision. Report 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) if the physician excises a benign lesion or 11620 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) if she performs a malignant lesion excision, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.
 
Why: The internist excised the entire lesion to the defined depth (full thickness), Cobuzzi says.

Use Biopsy Code for Diagnostic Removal

Correct coding tip: Research the operative report to determine why the physician performed the procedure. Internists excise lesions to remove the entire piece, but physicians take biopsies to obtain diagnostic specimens (this helps them decide whether they should take further action at the lesion site). The completeness and depth of the lesion removal - not the method (for instance, punch, scalpel, etc.) - determine whether the physician performed a biopsy or lesion excision.
 
Question #2: An internist sees a patient with rough skin on her chin. The physician suspects carcinoma  and takes a 3-mm punch biopsy of the tissue. He then closes the site with 4-0 ethilon sutures in a simple interrupted fashion.
 
Solution: You should use a biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.
 
Reason: The internist took a "biopsy" of the tissue sample to obtain a diagnosis, and didn't simply remove the lesion.