Podiatry Coding & Billing Alert

Measuring the lesion's margin gives you no advantage.

Rules that apply for lesion excision codes (11400-11646) may not necessarily work for shaving of epidermal or dermal lesions codes (11300-11313). You may even confuse 11300-11313 with a biopsy code.

Test yourself with the validity of the following facts, and be able to identify the codes properly.

Consider Depth to Distinguish Shaving

True or false: To differentiate between shaving (11300-11313) and excision (11400-11646), you should first look at the removal's depth.

Answer: True. Anytime the physician removes skin tissue, he's performing an "excision." For coding purposes, however, CPT narrowly defines an excision as involving "fullthickness (through the dermis) removal of a lesion." Shaving, by comparison, involves "sharp removal ... without a full-thickness dermal excision."

Shaving implies a superficial removal, says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates. In some cases, the physician may remove the raised portion of a benign lesion and allow additional lesion tissue to persist in the dermis.

Look into the physician's method to remove a lesion better reveals the difference between shaving and excision. During shaving, the physician uses a "transverse incision or horizontal slicing," as CPT says, to remove the lesion. That is, the physician holds the blade horizontal to the skin and moves it across the lesion, literally shaving it off.

Excision, in contrast, usually involves holding the blade perpendicular to (and thus cutting through) the skin to remove the lesion at a greater depth. In these cases, the physician always wishes to remove the entire lesion to the greatest necessary depth.

Another clue could help you differentiate between shaving and excision. While excision frequently requires suture or separate repair, shaving does not require suture closure, according to CPT.

Your safest bet, however, goes to reading the documentation carefully, notes Bishop. Physicians may use terms like 'shave biopsy' for a procedure CPT might describe as an excision, he says.

For Shaving, Rely on Lesion Size Only

True or false: When reporting shaving procedures, you may consider the size of any margin the physician removes with the lesion.

Answer: False. In fact, the physician may not document, or even take, a margin of tissue during a shave. This is a crucial difference from coding for excisions. For coding purposes, you should know that shaving codes comprises 3 categories, with 11305-11308 specific to scalp, neck, hands, feet, or genitalia. Within this category, CPT further divides the codes by the lesion's size. For instance, 11308 applies for a lesion of the scalp, neck, hands, feet, or genitalia measuring over 2.0 cm in diameter.

Code Per Lesion

True or false: You may report one code for each lesion that the physician removes by shave technique.

Answer: True. In fact, the descriptors for 11300-11313 specify "single lesion." If, for instance, the physician shaves 16 dermal lesions, you may report an appropriate code for each shaving. If the physician does shave an extraordinary number of lesions during a single session, you may have to submit documentation to explain the situation.

An alternative for some payers would be listing each removal as a separate line item, with modifier 59 (Distinct procedural service) appended to the second and subsequent identical codes, says Bishop.

Don't miss: CPT guidelines states that removal of epidermal or dermal lesions using shave technique includes local anesthesia and, if necessary, chemical or electro cauterization to arrest bleeding. Do not even attempt to code anesthesia services separately.

Finally, Watch Out for Biopsy Confusion

Physicians would sometimes submit samples taken using a shave technique for pathological examination. But whether the result is benign, malignant, or uncertain has no bearing on your CPT coding.

Background: CPT instructions preceding biopsy codes 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), and 11101 (...each separate/additional lesion [List separately in addition to code for primary procedure]), specifically site "shave removals" as one way to obtain tissue for pathological examination. This has added to the confusion of differentiating between 11100-11101 and 11300-11313. Your physician's intent may be your way out of the dilemma. A physician will remove by shaving a lesion that she suspects is benign, according to M. Trayser Dunaway, MD, FACS, CSP, author and educator with Healthcare Value in Camden, S.C. Although she may submit the tissue for biopsy, you should still select an appropriate shaving code rather than the biopsy code (biopsy is included in the shave).

What about a suspected malignant lesion? A physician may use shaving to remove a portion of the tissue for examination, with the intent of removing the entire lesion by excision if pathology confirms malignancy. In this case, you would apply the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and, if circumstances require, the appropriate lesion excision code (11600-11646) at a later session.

Alternative: If the pathology report did not reveal malignancy, you should report the biopsy code instead of 11300-11313. Remember, the intent was to obtain sample tissue for examination, not to remove the lesion.