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aaseals32

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Baker, LA
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Can someone please tell me if this would be coded as 11102 or 11310. Thanks

Shave excision, curettage and electrodesiccation performed. Telephone follow-up with
pathology results

Procedure

Informed consent obtained
Sterile prep performed left temple
Injection 0.5 cc 2% lidocaine with epinephrine locally to lesion left temple
Shave excision performed removing entire lesion on left temple. Specimen sent to pathology.
Curettage followed by electrodesiccation then performed. Good hemostasis. Band-Aid applied.
Procedure tolerated well without complication

Chief Complaint
Removal skin lesion left temple
History of Present Illness
Patient with history of recurrent actinic keratosis on the left temple previously treated with cryotherapy. Has new growth over the last 6 months. Here for shave excision and biopsy.

Physical Exam
Skin
Examination of the skin for lesions: Abnormal. Left temple with 6 x 8 mm red hyperkeratotic papule.
Pathology report:

Material submitted: .
DERM, TEMPLE - Skin, Left Temple, Biopsy:

Diagnosis: HYPERKERATOTIC ACTINIC KERATOSIS, WITH FOLLICULAR EXTENSION, INVOLVING THE DEEP AND PERIPHERAL BIOPSY MARGINS.
Received in formalin labeled with patient's name and date of birth, left temple is a 0.5 x 0.4 cm tan-brown fragment with a roughened surface. The specimen is inked red, bisected and submitted in toto in 1 cassette. Grossing tech: NAW
L57.0
 
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aaseals32 said:
Skin, Left Temple, Biopsy
Click to expand...
Biopsies are done on almost every procedure that involves the removal of tissue from the patient, and considered and incidental part of the more extensive procedure. So you would only code for a biopsy if the provider just took a sample of the lesion. Since the provider stated that the entire lesion was removed, you code the excision, and the biopsy is already included in that.
 
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thomas7331 said:
Biopsies are done on almost every procedure that involves the removal of tissue from the patient, and considered and incidental part of the more extensive procedure. So you would only code for a biopsy if the provider just took a sample of the lesion. Since the provider stated that the entire lesion was removed, you code the excision, and the biopsy is already included in that.
Click to expand...

I agree with Thomas. The biopsy code would be reported when the procedure was performed for the specific purpose of obtaining a sample for diagnostic examination.

In this case, the procedure was performed for the purpose of the excision.
 
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