Primary Care Coding Alert

Hint: Look for complete versus partial removal

Test your biopsy and excision skills with operative notes. See if you know how to code the following three procedures:

Tip: Family practice coder Shari Aloway, CPC, from Flowertown Family Physicians highlighted key terms to help you out.
 
Report Excision for Entire Lesion Removal ...

Procedure 1: Patient presents with a raised, suspicious-appearing, 2-mm lesion on her right arm. Family physician (FP) completely removes lesion using a 3-mm punch excisional tool and closes the surgery site with one 4-0 ethilon suture.

Code 1: In this case, the FP removes the entire lesion. Therefore, you should report excision code 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) or 11600 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less) depending on the pathology report. Excision includes simple closure, so  don't separately report the suture.

... and for Full-Thickness Removal

Procedure 2: An FP examines a very dark brown, multicolored, irregular-shaped 3-mm lesion on a patient's right medial shoulder. The physician uses a 4-mm punch excision tool to remove the lesion to full thickness. She then closes the site with two 4-0 ethilon sutures in a simple interrupted fashion.

Code 2: You should report 11400 for a benign lesion excision or 11600 for a malignant lesion excision. The FP takes the entire lesion to the defined depth (full thickness) an excision requires.

Use Biopsy for Partial Removal

Procedure 3: A patient points out some rough skin on her right lateral shoulder. Because she says the area looks similar to squamous cell carcinoma that she previously had, the FP takes a 3-mm punch biopsy of the tissue. He then closes the site with one 4.- ethilon suture in a simple interrupted fashion.

Code 3: Here, you should use the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). The FP takes the tissue sample to obtain a diagnosis, not to remove the entire lesion.