Wiki Punch Biopsy Documentation

[jojo1uf]

Hi All,

Provider ordered "Punch Biopsy" (CPT 11104). Below is provider documentation. Does the provider need to state in her documentation that a "punch biopsy" was performed? I would think so. But, welcome your input. Thanks!!


Procedure note:
RBA of procedure discussed with pt, including discomfort, infection, bleeding, perforation and damage to surrounding tissues and organs.

Under sterile conditions, Right groin skin prepped with iodinex3. Skin lesion biopsy performed under the local anesthesia with 1% Lidocain . Pt tolerated procedure well. Good hemostasis with silver nitrate . Bacitracin applied to area of bx
Samples of Bacitracin provided to pt , pt instructed to apply 2-3 times / day x 5 days


Thanks,
Jo

 

[Chelle-Lynn]

Since the coding requirements for biopsies have been updated to differentiate between tangential, punch, incisional, etc we have advised our providers to ensure that they include the how the sample was obtained to ensure that we are "clean" when coding.