Wiki Biopsy / Shaving

[lindafay1123]

I wanted another opinion as to if this would be coded as a biopsy 11100 or as a shaving. I believe biopsy and co-worker says shaving. Can someone help clear this up and help me to understand the guidelines as to what is consider a biopsy. Thank You

Site #1: neoplasm of uncertain behavior of skin 238.2 (upper x1)
Diagnosis status: worse
Procedure: Biopsy lesions with shave biopsy
Clinical comment: rule out BCC. Lesion size: 0.5 cm diameter.
Indication of procedure today: growing
Pre Op Size: 0.2 x 0.4 cm
Post Op Size: 0.2 x 0.4 cm
Local anesthesia: lidocaine 1% with epinephrine (1mL)
A sample of the lesion was removed by shave biopsy to the level of the dermis and submitted to pathology. Hemostasis was obtained utilizing electrocautery.

 

[JFoushee12]

It is my understanding that, for a shave removal - the intent is to remove the lesion - not just a portion of it as with a biopsy. However, I have also been told that when it is documented as "shave biopsy" an auditor may down-code a biopsy to a shave removal. I was told it is better to document it as a "biopsy by shave technique." You may want to send a message to the provider to clarify the documentation.

Did the provider have a path report back on the lesion that identified it as a lesion of UNCERTAIN behavior? Have to use 239.2 if not; can only use 238.2 when you have a path rpt to back it up.

Not sure if that helps at all. . . :0)

 

[monicahkfan]

I was trained that cpt 11300 is the shaving of the entire lesion and cpt 11100 is a sample of the lesion. Hope this helps.

 

[mitchellde]

The provide states he shaved a sample of the lesion therefore it is a biopsy, a biopsy can be either full or partial thickness. The dx code canot be a 238,2 as there is no pathology and the definition per your codebook for those codes is that they are histomorphopathologic. You also cannot use 239 codes as the provider did not call this a tumor or abnormal growth. If you use the codebook and look up the diagnosis, you go to key word lesion, then under that skin, this takes you to the 709.9 code which is the correct code to use.