Wiki Excision Conjunctival Lesion CPT Help

[arkolab]

I am needing some advice on the below procedure note that one of our Eye Doctors preformed on a patient in the clinic. The Doctor had billed CPT 68110 but wondering if this is appropriate given she didn't actually "excise" anything. Is there a different CPT to bill or would I be better off billing CPT 11200-skin tag removal if CPT 68110 is not appropriate.

Preoperative Diagnosis: Conjunctival Lesion, left eye
Postoperative Diagnosis: Same
Procedure:. Excision Conjunctival Lesion
Surgeon: M.D.
Anesthesia: Topical
Complications: None

Indications for this procedure: Patient has noted a conjunctival lesion in
her left eye. Examination revealed the presence of vascular conjunctival
lesion left upper eyelid margin.

Informed consent: The risks, benefits, and alternatives to excision of a
conjunctival lesion were explained to the patient. The patient indicated
her understanding and wished to proceed with excisional biopsy.

Procedure in detail: Patient was brought to the minor procedure room. The
patient was given a drop of proparacaine in her left eye. A Vannas
scissors was used to remove the lesion. TobraDex ointment was applied at
the end of the case. Patient tolerated the procedure well and there were no
complications.

 

[natashalage]

Hello, I am not an expert. I code and still learning this specialty. To me, it's clear 68110 but MD need to document the size of the lesion excised. MD used 'scissors' means he cut the lesion out. 11200 is for skin but in our case, MD cut out the part of Conjunctiva ( eye transparent part); not a skin. So, your codes are between 68110-68115. The procedural notes can be very short and not detailed unfortunately. The key words: excised lesion of conjunctiva.

 

[kmdnine]

I wouldn't worry about the size. The purpose of the excision appears to be for a biopsy, so I would go with the biopsy code 68100.