Oncology & Hematology Coding Alert

Narrow down to site of biopsy for the most accurate codes.

Site specificity is key to skin biopsy coding though you may often be spontaneously looking at less specific options. One code of interest can be 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). This code does not explain the biopsy site and may not always qualify as the right choice for all skin biopsies. In other words, you need to consider all options before universally submitting 11100 for all skin biopsies. We have provided some expert guidance for skin biopsy procedures.

You May Be Missing More Work in the Skin

Site-specific biopsy codes tell the payer the physician performed a biopsy at a specific site, rather than a generic integumentary based biopsy (11000). A site-specific biopsy code also represents a more complicated procedure than 11000 represents.

More pay: Your physician deserves more pay for the higher level of complexity of these site-specific procedures. Your practice may be losing income if your physicians overlook these site specific codes, which is easy to do because once you read skin biopsy, you may focus on the integumentary section of the CPT® manual.

Tip: If the physicians in your practice often forget there are site-specific biopsy codes, you can help them remember by including a list of the site-specific biopsies on your encounter form or selections for charging in the electronic charge capture system to reinforce the options. Consider the following examples to differentiate site specific codes from 11100.

Example 1: A patient presents to your practice with a red papular lesion of the lip. After the physician examines the patient, he determines he must perform a biopsy.

In this scenario, you would report 40490 (Biopsy of lip), instead of 11100.

Example 2: A patient with a long history of pigmented lesion of the nail bed presents to your practice. The physician decides to perform a nail bed biopsy to rule out melanoma.

Your first thought in coding this scenario might be to bill 11100. You should instead bill 11755 (Biopsy of nail unit [e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds] [separate procedure]) based on the description of the biopsy being performed.

Compare the reimbursement difference:

"In Example 1, the code 40490 is the correct choice based on the description and the reimbursement is over $20 more than if reported with 11100," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services ("PERCS"), a division of Pinnacle Healthcare Consulting.

In Example 2, the code 11755 is more accurate and also pays approximately $30 more than code 11100 (3.78 non-facility RVUs x $35.8043 = $135.34).

Reimbursement is higher for different reasons based on the specific procedure performed. For instance as In example 2, when your physician performs a nail bed biopsy, he cuts through the plate, biopsies the nail bed, and may suture the wound requiring a different process and work/effort than a typical skin biopsy.

Count Sites and Submit Multiple Biopsies

When your physician performs multiple biopsies, you need a tool to unlock the claim's payment. It is important to determine how many sites were biopsied and if the sites biopsied were distinct.

Example: Your physician performs a biopsy of a lesion on a patient's leg and another biopsy on the patient's eyelid during the same visit.

Focus on sites: Because your physician specifies the site in the detailed documentation, you can see the documentation justifies reporting 11100 for the biopsy on the patient's leg and 67810 (Incisional biopsy of eyelid skin including lid margin) for the second biopsy on the eyelid.

More about 11100: You submit code 11100 when your physician samples a part of the skin lesion for histopathology. You may select to report this code for punch biopsies, curettings, and scissor biopsies. This code also applies to sampling of ulcer edge with a scalpel in an attempt to rule out neoplasia.

Also: You should consider code +11101 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; each separate/additional lesion [List separately in addition to code for primary procedure]) for additional skin biopsy sites.

When reporting sampling by a shaving or saucerization technique, you submit code 11300 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less) – 11313 (Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm).