Three Tidbits Help You Code Lesion Biopsy and Removal

As always, careful review of the documentation is necessary for correct coding, as well.

By Brenda Chidester-Palmer, CPC, CPC-I, CEMC, CASCC, CCS-P
When documented by a physician, the simple statement “removal of lesion” can lead to many different coding choices. To choose the correct code, you will need three precise pieces of information:

1. The type of lesion
2. The location of the lesion
3. The exact service performed (e.g., biopsy or excision)

Lesion, mass, and lump are common terms physicians use when planning a biopsy or excision. Lesions can be benign or malignant, cysts or tumors, or even warts or skin tags. In most cases, you will not know if a lesion is malignant or benign until the pathology report is final. Waiting for the path report is key to proper code selection.

Biopsy Occurs for Pathology Exam Only

A biopsy removes only part of a lesion for study by a pathologist. An excision or removal, by contrast, eliminates the entire lesion/neoplasm. The removed lesion also will be sent to the pathologist for biopsy. Physicians often will document, “removed and biopsied a lesion.” This does not mean you may bill both a biopsy and an excision. Rather, the biopsy will be included in the excision and is not separately reportable.
For example, the physician removes what appears to be a benign lesion from the arm. She sends the tissue to pathology to be sure it is not cancerous. In this case, you would report the proper excision code and the correct pathology (ICD-9-CM) code, but not the biopsy procedure code.
CPT® 11100-11101 describe biopsy, or taking of a specimen for pathologic purposes only. The intent is not to remove the entire lesion or area, although the total lesion may be removed, at times.

Other biopsy codes throughout the surgery subsections are not for biopsy of lesions, but for biopsy of actual muscle, or a part of the lip. For example:

20200         Biopsy, muscle; superficial

20205                      deep

40490          Biopsy of lip

40808          Biopsy, vestibule of mouth

50200           Renal biopsy, percutaneous, by trocar or needle

Many physicians use the term “shave biopsy.” This can be confusing when coding because there is not a CPT® with this exact verbiage. Your choices include 11100-11001 (biopsy) or the 11300-11313 shave excision codes. Careful review of the documentation and/or query of the physician is necessary for correct coding.

Removal Can Occur by Various Methods

Removal can occur by freezing with liquid nitrogen, shave excision, excision, or destruction—basically, any form of removal that the physician performs.
Ligature strangulation is a removal technique used mainly on skin tags. The physician loops suture material into a circle, places the circle over the pedicle, and pulls tight to sever the skin tag. Correct CPT® codes for this type of removal are 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions and +11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure). Note that 11200 and +11201 describe skin tag removal by any method, including chemical destruction, electrosurgical destruction, or any combination of methods. In other words, skin tag removal code selection is not based on the removal type, but on the number of lesions removed.
Paring or cutting (also called peeling or scraping) is a technique used for benign hyperkeratotic skin lesions, such as corns or calluses. A small spoon or ring-shaped instrument (curette), or similar sharp instrument, is used to gently scrap or pare the lesion. Bleeding is controlled by a chemical applied to the surface after removal. CPT® 11055-11057, depending on the number of lesions removed, describe this service.
For example, a patient presents with painful corns on the fifth toe of her left foot and the fourth toe of her right foot. The physician pares or scrapes off the corns in several layers. The correct code is 11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions because two corns are removed.
Shave excision is not a full thickness dermal removal, but involves a transverse incision or horizontal slicing to remove the lesion just to the level of the skin. This removal technique does not require suture closure of the defect. Chemical or electrocauterization of the wound is included to control the bleeding. Code selection is based on anatomic location and size:

• 11300-11303 (trunk, arms, or legs)
• 11305-11308 (scalp, neck, hands, feet, genitalia)
• 11310-11313 (face, eyelids, nose, lips, mucous membranes)

Measurement should include the lesion only; margins are not included in this type of removal.
For example, a patient presents with a 1.0 cm benign lesion on the right wrist, which has been irritated by his watchband. The physician injects the area with Lidocaine and makes a transverse incision to remove the lesion to the skin level. Chemical is applied to control bleeding. In this case, the correct code is 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm.

Coding Lesion Ablations

Destruction means ablation: The lesion is completely destroyed, leaving nothing to send to pathology. This form of removal can be used on benign and malignant lesions, as well as warts, condylomata, or other lesions. Destruction can be performed by several methods:

• Currettage is performed using a spoon shaped instrument to scrape or scoop out the lesion in pieces. This technique can be performed alone, or with chemical or other types of destruction.
• Chemical destruction involves applying chemicals directly (by brush, swab, or injection) to a lesion. Typically, the chemicals used are liquid nitrogen (LN2), trichloracetic acid, cantharidin (on warts), and salicylic acid. Chemical destruction is used when the lesion is sure to be benign, or for malignant lesions when the cancer is known to be in-situ (not spread to surrounding tissues).
• Electrosurgical destruction is a general term that encompasses the different procedures using electrically generated heat. There are many types of electrosurgery, as seen in Table  A on the preceding page.
• Lasers can be used to destroy lesions or warts, but this is not the preferred method.

Table A

 
Coding for destruction of lesions is not based on the method of destruction. Instead, it is based on the type and location of the lesion(s), and how many are being destroyed. Under the Destruction subheading in CPT®, there are two categories: Benign or Premalignant Lesions and Malignant Lesions, Any.
Table B

As shown in Table B, codes are specific for lesions in certain anatomical sites. If there is not a code in a specific section, you would instead use codes from the integumentary section. For example:
30117         Excision or destruction (eg, laser), intranasal lesion; internal approach
40820        Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical)
45190         Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach

Differentiate Skin vs. Soft Tumor Excision

Surgical excision requires an incision, several types of which you may see documented in the procedure or operative note (e.g., longitudinal, elliptical, or transverse). The incision, or approach, tells us whether this was a skin lesion or a deeper mass (different CPT® codes describe a lesion on the skin versus a mass in the soft tissue). You also need to know the size of the lesion(s).
In coding for skin lesion removal, there are codes for benign lesions and malignant lesions (as shown in Table C). These are further divided by size of the excision and anatomical location.
Table C

Another factor in choosing the correct code for skin lesion removal is the area, or margin, around the lesion that also was excised. Add this area to the lesion size and select the code based on the total sum of the margin and the lesion.
For example, the patient has a 2.4 cm malignant lesion on the upper right arm, with involvement of surrounding skin/tissue. The lesion is excised along with a 1.5 cm surrounding margin. The lesion and margin added together equal 3.9 cm, so we would choose 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm.
If an incision is made to remove a mass or tumor in the subcutaneous tissue or below, code from a different subsection entirely. The type of lesion/mass and where it is located are determining factors. Codes for excision are found all throughout the musculoskeletal system: neck and thorax; back and flank; abdominal wall; shoulder, upper arm and elbow area; forearm and wrist; hand and fingers; pelvis; thigh or knee area; lower leg or ankle area; and, foot and toe area. These codes are selected based on the lesion or mass being subcutaneous or subfascial and on size (< or > 2 cm). Example codes include 21011-21012, subcutaneous of face or scalp; 21013-21014, subfascial face or scalp; and, 21015-21016, radical (malignant) face or scalp.
There are also codes for this type of excision throughout the surgery subsections. Some of these codes are divided based on repair type (if necessary). For example:
40810         Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
40812                 with simple repair
40814                  with complex repair
For example, a patient presents with a lesion on the anterior portion of the tongue. The physician decides to remove the lesion and send to it pathology. The physician injects the area with Lidocaine, makes an elliptical incision around the lesion, and removes the lesion entirely. The area is closed with a simple suture using Vicryl. In this case, the correct code is 41112 Excision of lesion of tongue with closure; anterior 2/3. This code includes the excision and the closure, so a separate repair code would not be reported.
Although outside the scope of this article, you must be sure that your diagnosis (ICD-9-CM) coding matches the CPT® codes being billed. For example, you should not bill for an excision of a cyst with a diagnosis of a malignant lesion or wart. Correct coding of both procedure and diagnosis is the key to getting correct reimbursement.
Brenda Chidester-Palmer, CPC, CPC-I, CEMC, CASCC, CCS-P, has 17 years of coding and billing experience. Brenda is the principal of Palmer Coding Consultants, and former coding compliance manager for a large multi-specialty group practice in Houston. She is PMCC instructor, AAPC workshop and national conference presenter, past president of her local AAPC chapter, and a former member of the AAPC National Advisory Board (NAB).