Primary Care Coding Alert

You'll never lose excision dollars again if you know the key terms to look for in your FP's documentation.
 
Many family physician (FP) coders have difficulty determining whether their FP's notes describe a biopsy or an excision. "Our office is having a debate on when to use the 11100 versus 11400 codes," writes Sharon Witt, CPC, a coding reimbursement specialist at Upper Valley Professional Corporation, which serves 40 FPs in Miami County, Ohio.

To decide which code to use, follow these steps:

1. Look for Lesion Removal Amount

The easiest way to distinguish an excision (such as 11400, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) from a biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) is to check how much of the lesion the FP removes. Check your physician's documentation for partial or complete removal, says Shari Aloway, CPC, a family practice coding specialist at Flowertown Family Physicians in Summerville, S.C.

The lesion removal amount usually determines whether you should report a biopsy or an excision. For instance, if your FP takes a piece of the lesion, you should report a biopsy, Aloway says. "If he removes the whole thing, it's an excision."

To get to the right code family -- biopsy or excision -- use the following handy chart.  
  
Snag: Unfortunately, if your FP uses a punch technique to remove an entire lesion because of its small size, you may have to throw the above coding rule out the window. In these cases, even though the FP removes the whole lesion, he may actually perform a biopsy. The lesion's size simply makes removing the entire lesion easier than taking a piece of it, says Pamela J. Biffle, CPC, CCS-P, an independent consultant in the Dallas/Fort Worth area and an American Academy of Professional Coders instructor.

You also shouldn't assume that using a "punch tool" means that your FP performs a biopsy. Sometimes he may employ the straw-like, sharp instrument to excise a lesion.

Therefore, ambiguous terms, such as "punch biopsy," "excisional biopsy" or "completely removed with punch biopsy," don't tell you whether your FP performs an excision or a biopsy. In these cases, you instead need to look at two other factors.

2. Focus on Depth

First, look for clues that tell you how deep the cut is. "Excision is defined as full thickness (through the dermis)," according to CPT's excision notes.

Translation: An excision requires removing the entire lesion to the subcutaneous level, Biffle says. If you see terms such as "full thickness," "subcutaneous" or "through the dermis," you should report an excision (11400-11646), she says.

3. Check the Intent
 
If documentation doesn't mention the excision's depth, look for the physician's intent. Ask yourself, "Why did the FP perform the procedure?" Aloway says.

The answer is the key to your code selection. In a biopsy, the FP takes the sample to get a diagnosis, Biffle says. He performs an excision to remove the entire lesion.

In either case, the physician may send a specimen to pathology. A pathology report doesn't signal a biopsy or an excision.