Wiki Shaving or Excision Code

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BABS37

BABS37

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Does this just look like 11310 for shaving biospy versus 69100 biopsy of external ear? Thoughts on how others would code?

Office Procedure Procedure: Shave biopsy of the left ear Informed consent was first obtained. Next the left external ear was cleaned with alcohol and 1% lidocaine with 1-100,000 epinephrine injected around the lesion. A shave biopsy was then taken of the area and placed in formalin for histologic evaluation. Hemostasis was maintained with silver nitrate. He tolerated this well with scant bleeding.

Assessment and Plan

ICD: Neoplasm Of Uncertain Behavior Of Skin (238.2)
 
I would go with the 69100. 11310 states it is for a lesion. Where as 69100 is more for a biopsy, which seems more appropriate with the diagnosis you provided.
 
I'm afraid I disagree. The 69100 code is for a punch or excisional biopsy of the external ear. Since your provider clearly did a shave approach (and did not mention scalpel or punch), and didn't suture the defect, I'd go with the codes in the 1131x. You will have to query the provider about the size, however, and not just code to the lowest code because you don't know. Without the size documented, the code is not supported.

The diagnosis would not drive the procedure code in this case.
 
Whoops! Sorry about that- the EHR system automatically assigns a dx and most derm procedures get 238.X but we don't use those. I will wait for the path report. The actual note for this one was "persistent superficial ulcerative lesion involving the left external ear at the helix..."

Thank you Pam! I just thought 69100 wasn't really supported since he said 'shaving.' My provider wants 69100 and I wanted 11310 series. I'm just not so sure he will agree with me when I email him and ask for the lesion diameter... :(
 
BABS37 said:
Whoops! Sorry about that- the EHR system automatically assigns a dx and most derm procedures get 238.X but we don't use those. I will wait for the path report. The actual note for this one was "persistent superficial ulcerative lesion involving the left external ear at the helix..."

Thank you Pam! I just thought 69100 wasn't really supported since he said 'shaving.' My provider wants 69100 and I wanted 11310 series. I'm just not so sure he will agree with me when I email him and ask for the lesion diameter... :(
Click to expand...

I agree with Pam, I would also add that it is very important that your provider stay away from terms such as shave biopsy as this is very misleading. The requirement for the 113xx series is size and of course, location. If your provider did not document the size prior to removal then you are left no choice but to code the 11310, you can NOT refer to the pathology report for the size of the lesion. Also I would strongly suggest fixing the issue with your EHR assigning the wrong diagnostic code. You could actually submit the 11310 with a diagnostic code of 239.2 and from what I have researched, most payers will accept and pay with that diagnosis appended.
 
You are correct that shave biopsy is misleading, he either performed a biopsy OR he performe a shave removal. The documentation is insufficient to determine. A biopsy by definition is a removal of a piece of a larger anomaly. A shave is a removal of the entire visible anomaly to a depth of partial thickness.
You cannot assign a 238.x dx code without a path report.. if you need confirmation of this look in your ICD-9 book the definition is there. histomorphologic means you need a path report.
You cannot assign a 239.x code when the provider documents "persistent superficial ulcerative lesion" cannot be interpreted as a neoplastic process and cannot be coded as such. Per coding clinic a 239.x code can be assigned only after a preliminary diagnostic report reveals that the symptom of "mass" or "lesion" is a "new growth" or a "tumor".
 
I feel like a late arrival to the party chiming in here, but why not consider a straight 11100? I think I understand Susan's and Debra's comment about "shave biopsy" being misleading sometimes, but as an MA, that is exactly what I used to assist with. The provider would take a sample by shave technique with no therapeutic intent. Particularly on an ulcerated lesion of the ear. The clinical differential was often SCC, and the plan for more extensive surgery pending path. In the case of Babs's provider, he took a "shave biopsy of the area". I would be curious to see the entire note including the clinical diagnosis.

Now I did have a provider who often did shave removals of clinically atypical nevi and did not document clearly until I went from being her MA to her coder (That's where I agree with Debra and Susan that "shave biopsy" can be misleading. I watched my doc's technique for years and knew exactly what procedure she was performing. Once I knew the difference from a coding perspective, we worked out the documentation issue from there.)
 
Debra,

Absolutely agree with you, but the clinical background does help me identify holes in documentation. It also gives me a starting place for changing those documentation practices to more accurately reflect what's happening in the room. If I know Doc A shave removes almost all her clinically atypical nevi, but keeps documenting it as a biopsy, I can open the subject with her by saying "Doc A, when I used to work with you, I noticed this... but when I read your note, it says that." It's a more gentle, diplomatic opening than merely pointing out to her that she's wrong. ;)

And would anyone else have gone for 11100 for the OP's question? Why can't a shave biopsy be just a shave biopsy?

Thanks,

Katie
 
I would agree that it should be 11100. 11300-11313 is for shave REMOVAL of lesions, indicating the entire lesion is removed via shave technique. 11100 is for a lesion biopsy, meaning only a portion of the lesion is sampled via any biopsy technique.
 
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