briannah
Guest
hello, if anyone can help here, I'd greatly appreciate it. The verbiage on the note is as follows:
R. post. thigh: Procedure: Shave biopsy. We discussed the differential diagnosis with the patient and the importance of shave biopsy in facilitating diagnosis. Furthermore, I stressed that the information garnered from biopsy may help guide treatment. The patient fully understands that the lesion in question needs to be biopsied and neglecting biopsy of the lesion could delay or hinder successful treatment. The patient agreed to undergo shave biopsy. Verbal and written informed consent was obtained. Benefits, risks, side effects, and alternatives with the procedure were thoroughly reviewed. I specifically explained that there will be a scar following the procedure. Additional risks including pain, infection, and discoloration/pigmentary change were reviewed. The lesion in question was cleansed with an alcohol swab. It was then marked with a marking pen and the site was confirmed with the patient. Local anesthesia was then achieved using lidocaine diluted with epinephrine 1:100,000 (< 1.5 cc total volume used). The lesion was biopsied using a sterile dermablade. Hemostasis was easily achieved using pressure and aluminum chloride. The wound was dressed with vaseline and a bandage. Wound care instructions were carefully reviewed. The patient understands to apply vaseline and a bandage to the area daily until the wound heals. There were no complications. The specimen was sent to pathology. We will contact the patient with the biopsy results and arrange the appropriate follow-up.
Doctor used cpt 11100, insurance denied after reviewing the chart stating documentation does not support the charge. He also billed an excision but that was documented and coded separately. I advised the doctor based on the documentation he should have billed a 113xx code not the 11100. He thinks that is wrong.
Does anyone have any insight to this?
Thank You,
Brianna
R. post. thigh: Procedure: Shave biopsy. We discussed the differential diagnosis with the patient and the importance of shave biopsy in facilitating diagnosis. Furthermore, I stressed that the information garnered from biopsy may help guide treatment. The patient fully understands that the lesion in question needs to be biopsied and neglecting biopsy of the lesion could delay or hinder successful treatment. The patient agreed to undergo shave biopsy. Verbal and written informed consent was obtained. Benefits, risks, side effects, and alternatives with the procedure were thoroughly reviewed. I specifically explained that there will be a scar following the procedure. Additional risks including pain, infection, and discoloration/pigmentary change were reviewed. The lesion in question was cleansed with an alcohol swab. It was then marked with a marking pen and the site was confirmed with the patient. Local anesthesia was then achieved using lidocaine diluted with epinephrine 1:100,000 (< 1.5 cc total volume used). The lesion was biopsied using a sterile dermablade. Hemostasis was easily achieved using pressure and aluminum chloride. The wound was dressed with vaseline and a bandage. Wound care instructions were carefully reviewed. The patient understands to apply vaseline and a bandage to the area daily until the wound heals. There were no complications. The specimen was sent to pathology. We will contact the patient with the biopsy results and arrange the appropriate follow-up.
Doctor used cpt 11100, insurance denied after reviewing the chart stating documentation does not support the charge. He also billed an excision but that was documented and coded separately. I advised the doctor based on the documentation he should have billed a 113xx code not the 11100. He thinks that is wrong.
Does anyone have any insight to this?
Thank You,
Brianna
