Oncology & Hematology Coding Alert

Base your CPT^® code on lesion size, location, and malignancy.

Whenever your oncologist sees a patient for skin or skin structure cancer lesions, you should ensure accuracy in reporting of any biopsy your physician may do. Although capturing these procedures are simple, missed reporting can result in big losses. Here are answers from experts for the top 5 most frequently asked questions about site-specific integumentary biopsies.

Q: What’s the difference between an excision and a biopsy? 

A: When the physician intends to fully remove a lesion, he performs an excision. If the goal is to obtain a sample of the lesion for pathology, a biopsy is performed. CPT^® codes 11102-+11107 are selected based on the type of biopsy performed. Report CPT^® code 11102 (Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion) if a single tangential biopsy is performed. You would add 11103 (…each separate/additional lesion [List separately in addition to code for primary procedure]) for any additional separate/additional tangential biopsy(ies).

A punch biopsy of a skin lesion involves using a specific punch tool to achieve a full thickness, barrel shaped or columnar shaped specimen.  Report 11104 for the initial lesion and +11105 for each additional lesion. An incisional biopsy of a skin lesion is performed using a sharp blade to obtain a full-thickness specimen via a wedge or vertical incision, and may involve specimens of subcutaneous fat. Report 11106 for the initial lesion and +11107 for each additional lesion.

“The specific location of each biopsy should be clearly supported by documentation,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC. “Often the physician will draw a picture of the location in handwritten notes. In an EMR, pictures of the lesion locations can be a challenge, so a clear verbal description should be evident.”

Simple surgical repairs of the biopsy site, regardless of the technique used, is included when reporting the biopsy CPT^® codes 11102-+11107.  Only closures requiring a repair supporting the definition of an intermediate or complex closure may be reported in addition to the biopsy.

If the procedure was performed and intended to remove/excise the lesion, the CPT^® code chosen will depend on the size of the lesion, where it is located, and whether the lesion is malignant or benign. Report an excision of benign lesions with codes 11400-11446 (Excision, benign lesion…).  A code from the 11600-11646 (Excision, malignant lesion including margins…) is used for malignant lesion excisions.

Don’t miss: Shave removals are another common source of confusion, says Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. Report shave removals with CPT^® codes 11300-11313 (Shaving of epidermal or dermal lesion, single lesion…), she says. The physician removes an elevated epidermal or dermal lesion after local anesthesia is injected beneath the lesion. A scalpel or similar surgical blade placed against the skin adjacent to the lesion. Then a horizontal slicing motion is done to excise the lesion from its base. When this technique is used, the wound does not require suturing and bleeding is controlled by chemical or electrical cauterization.

Biopsies are performed to determine the clinical pathology of the lesion. Once the nature of the lesion is known, and removal is necessary, the correct surgical excision codes can be assigned.  The anatomical pathology result diagnosis as documented by the treating provider would also be assigned. 

Keep in mind: Payors may only cover lesion removal only when the pathology result supports a medically necessity reason for removal.  For example, Palmetto GBA, the Medicare Administrative Contractor, local coverage determination (LCD) L33445 states “Removal of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not covered by the Medicare program (statutory exclusion).”  Be sure to review the payor’s policy to determine whether the performance of the procedure meets their insurance policy coverage guidelines.  If not, you should inform the patient if a denial for coverage is expected, they may be required to pay for the cost of the procedure themselves.

Q: When should I report a site-specific biopsy code instead of 11102?

A: Any time there is a code more specifically describing the specific biopsy site, report the more specific biopsy code. This means you should not use 11102-+11107 if a biopsy code for the specific site exists elsewhere in CPT^®.

Your physician deserves more pay for the higher level of complexity of these site-specific procedures. Your practice is losing income site specific codes are not used when available.  This is easy to do since skin coding practices are most often found in the integumentary section of the CPT^® manual.

Example: A patient presents to your practice with a papular lesion of the lip. After your physician has examined the patient, he determines the patient needs a biopsy. Report 40490 (Biopsy of lip) here instead of 11102. As long the site and procedure is adequately documented, you should receive approximately $28 more for the procedure on the patient’s lip than if you had reported 11102, because this type of biopsy requires more work.

Medicare assigns 3.59 non-facility relative value units (RVUs) to 40490, which, when multiplied by the 2019 conversion factor of 36.0391, leads to $129.38 in reimbursement. Compare this to $100.91 for 11102 (2.80 RVUs). Often, oncologists take extra steps in a biopsy of the lip, including the use of a chalazion clamp to control bleeding.

Q: What are some of the site-specific skin biopsy codes?

A: These are some of the common ones, along with the Medicare Physician Fee Schedule non-adjusted payment if performed outside of a facility (based on RVUs multiplied by the conversion factor). Note that all of these site-specific codes are valued higher than 11102’s $100.91.

• 11755 (Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)) [$125.06]
• 30100 (Biopsy, intranasal) [$144.16]
• 40490 (Biopsy of lip) [$129.38]
• 40808 (Biopsy, vestibule of mouth) [$193.53]
• 54100 (Biopsy of penis; (separate procedure)) [$203.26]
• 67810 (Incisional biopsy of eyelid skin including lid margin) [$179.84].

Q: Should I wait for the path report to choose what code to report?

A: The pathology report would not change which biopsy code you report (however, it would change the excision code; see above). The pathology report will help determine is the diagnosis (ICD-10-CM) code to report when acknowledged by the treating physician. Therefore, for a complete and accurate claim, in rare cases where a biopsy was not performed in advance of the lesion removal, it is wise to wait for the pathology determination, Biffle advises: “It can change the code reported. For example, you think a benign lesion was excised but the path came back malignant.”