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Otolaryngology Coding Alert

Let Documentation Lead You to Lesion Sample, Removal Code

Published on Sun Feb 01, 2004

 

You can eliminate 11100 versus 114xx/116xx confusion if you look closely at your otolaryngologist's notes and can distinguish between the different types of biopsies and excisions.
 
While otolaryngologists may use the same instrument to perform a biopsy or excision, you shouldn't report these procedures the same way. So, knowing the difference between the operations is crucial to proper coding.

Two Details Separate Biopsy From Excision

Your otolaryngologist may take a sample of a large lesion or remove a small lesion with a punch tool, says Pamela J. Biffle, CPC, CCS-P, an independent consultant in the Dallas/Fort Worth area and a professional medical coding curriculum American Academy of Professional Coders-approved instructor. Using a straw-like, sharp instrument, he cuts or "punches" a perfectly round circle in a patient's skin. He then submits the specimen for pathology. But because an otolaryngologist can use a "punch biopsy" to biopsy or to excise a lesion, you may not be sure which code to choose.
 
You can quickly tell the difference between a biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and an excision (such as 11440, Excision, other benign lesion including margins [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) if you understand these two criteria:

 

  • Depth: A biopsy involves taking a small piece out of a large lesion. An excision requires removing the entire lesion to the subcutaneous level. 
     
  • Intent: In a biopsy, the otolaryngologist takes the piece to get a diagnosis. He performs an excision to remove the entire lesion.

    Look for These Key Phrases
     
    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), Biffle says.
     
    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, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

    Intent Is the Driving Force

    Sometimes your otolaryngologist may use a punch technique to remove an entire lesion because it is small. This doesn't necessarily mean he performed an excision (removing what the surgeon perceives as the entire lesion including margins). You instead need to look at his intent.
     
    For example, using a punch, an otolaryngologist completely removes a 1.0-mm lesion with 4-mm margins from a patient's cheek. Documentation reads: "My intention is to find out if the lesion is malignant." In this case, you should report a biopsy (11100), Cobuzzi says. "The surgeon performs the procedure to diagnose the lesion."
     
    On the other hand, suppose the otolaryngologist states: "Patient wants 2-mm ice-pick scar on cheek removed." Because the surgeon performs the procedure to remove the lesion, you should report an excision, Biffle says. Depending on the pathology report, you would report 11440 (benign lesion) or 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less).

    Expert Reveals Real-World Coding Secrets

    Operative reports, however, often don't include intent clauses. If you can't encourage your otolaryngologist to include this information, Cobuzzi recommends coding based on these guidelines shown in the chart.
     
    In either case, the otolaryngologist may send a specimen to pathology. A pathology report doesn't signal a biopsy or an excision, she says.

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