Wiki Documentation: Punch biopsy / excision

[BlakeCarswell82]

I work for a pathology lab. We are being asked to call specimens a punch excision instead of a punch biopsy to correlate with the client's verbiage so they can code for an excision versus a biopsy. To meet the criteria of being a skin excision, the CPT book says, "An excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed."

Our pathologists sometimes do not see the subcutaneous fat that proves the excision/biopsy is through the dermis, thus the criteria for "excision" is not met. However, the client's intent is to go through the dermis and, sometimes, the fat does not want to hang on as well with a punch procedure as with a scalpel procedure.

Do Medicare and other payers pay attention to the pathology report's verbiage and will anyone get in trouble in an audit if our verbiage does not match theirs. Also, can we document that the specimen is indeed an excision based on their intent, even though it does not necessarily meet our objective criteria?

 

[Saedron]

I go through this very thing with my providers all the time! I can only comment on what happens on the documentation and code selection on my end because I am unfamiliar with pathology requirements. But I can tell you, when I read a procedure note and I see "shave excision biopsy performed" I want to scream.

You are correct that is about intent. If the intent of the provider was to remove the lesion, then the decision to send the lesion for pathology is irrelevant. The lesion was removed, therefore it's a shave or an excision.

If the intent was to get a sample of the lesion through punch or shave and the entire lesion was not removed then it is a biopsy only regardless of how the sample was obtained (shave, punch). If the pathology report indicates the lesion should be removed, then we are back to removal by shave or excision after the fact.

Hope that helps!