Otolaryngology Coding Alert

Keep in mind that a tissue biopsy as described by 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) is distinct from excision 114xx/116xx (for example, 11440, Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less).

From a surgeon's standpoint, anytime he removes tissue for pathology analysis, he has performed a biopsy. From a coding standpoint, however, 11100 describes removal of only a portion of a cyst, fibroadenoma or other benign or malignant tissue for analysis, while excision as described by 114xx/116xx involves removing the entire mass. In either case, the surgeon may send the mass to pathology.

Warning: Don't let ambiguous terms, such as -punch biopsy,- -excisional biopsy- or -completely removed with punch biopsy,- mislead your code selection. If you see -full thickness,- -subcutaneous- or -through the dermis,- you should report an excision (11400-11646).

But when the otolaryngologist -wanted to see what the lesion was,- he's looking for a diagnosis. That should trigger you to report a biopsy code.

-No matter how the doctor titles the operative report, biopsy is a piece, and excision is the whole thing,- says  Kim Garner, CPC, CCS-P, CHCC.