Clear Up Blemished Dermatology Coding
By Jennifer Swindle, CPC, CEMC, CFPC, RHIT, CCS-P, CCP-P
There are many minor skin procedures performed in the medical office. It’s critical for coders and physicians to communicate effectively so documentation is clear and concise, coding is accurate, and reimbursement is appropriate.
Biopsies, excisions of both benign and malignant lesions, destruction of pre-malignant and benign lesions, removal of skin tags and shave removal of dermal and epidermal lesions may all occur but are coded very differently. The term “biopsy” is often used as a generic description and may lead to inaccurate reporting and coding of provided procedures.
Terminology confuses and frustrates physicians and coders when terms identifying the technique point to a possible coding error. What if the medical record identifies a shave biopsy or a shave excision? What is the accurate code selection? A shave removal is a separate procedure and does not truly support a biopsy or an excision; however, a physician often uses the term shave to identify the technique used to perform the procedure.
From a coding perspective, there are biopsy codes, excision codes, and shave removal codes. When the technique is shave, it does not change the overall purpose of the procedure. Coders need to translate from clinical language to coding language and communicate effectively. Ideally, documentation as written should exactly line up with the coding language. Clear and concise terminology makes coding much more accurate, for example:
A biopsy was taken of a lesion on Mary’s arm using a shave technique.
A shave removal was performed on the .65 cm dermal lesion on Mac’s chin.
A full thickness incision was made through the dermis to excise the lesion on Joe’s back. The size of the lesion including margins was 1.4 cm.
Would there be any question as to what code category should be used to report the above services? No. Terminology is very clear and directly ties to the biopsy code, a shave removal, and an excision. Let’s break these three very distinct services apart and review the correct codes.
Report skin biopsies with the CPT® code series 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion and 11101 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure). Code 11100 is reported for single lesion biopsy. This is a biopsy of skin, subcutaneous tissue and/or mucous membrane and includes simple closure. If more than one lesion is biopsied, 11101 is reported in addition to the code for the single lesion and should be reported for each additional lesion. CPT® code 11101 is an add-on code and can never be reported alone.
A biopsy code also does NOT determine the method used to obtain the specimen. Often a physician may report shave biopsy; however, this is still a biopsy. If the service’s intent is to obtain a lesion specimen to send to pathology for identification, the method does not change that the procedure done is a biopsy.
The biopsy intent is what makes this procedure different from an excision, destruction, or shave removal. A biopsy captures a separate and independent service. A biopsy is performed on a lesion or areas of the skin to diagnose skin diseases or conditions. The purpose is to remove a skin portion or the suspicious area to be examined in pathology for a definitive diagnosis. A biopsy is a biopsy—the method of how tissue was obtained does not change the code.
Other skin procedures, including shave removals and excisions, may also be submitted for a pathological finding. This is not a separate biopsy, but a component of the larger procedure, so a biopsy is not separately reportable.
Dermal or epidermal lesion(s) shaving should be reported with codes 11300-11313. The shaving procedure is epidermal and dermal lesion(s) removal without a full thickness dermal excision by transverse incision or horizontal slicing. This tissue removal does not necessarily support a biopsy and should not be coded as a biopsy.
Keep in mind, a shave removal is also not considered an excision. Excision codes should not be reported for this service.
Lesion removal by shave technique is a superficial removal and does not always constitute entire lesion removal. The depth and location often determine if the entire lesion is removed by shaving. Often, shaving is only done to get the surface back to flat.
Shave removal can be reported for benign or malignant lesions. The measurement of the actual lesion’s location and size (not including any margins) is necessary for proper code selection. Closure is not necessary with shave removal. Local anesthetic and electrocautery of the wound is included.
Skin Lesion Excision
There are multiple codes for reporting skin lesion(s) excision. Key criteria must be captured in the medical record: The lesion location, the lesion size including defect margins, and whether the lesion is benign or malignant. Pathology reports are necessary to accurately capture the correct excision code.
To perform an excision, a full thickness incision is made through the dermis with a scalpel to completely remove the lesion and the margins, usually under a local anesthetic. Simple closure is included in the excision and is not separately reportable; however, if a layered intermediate or complex repair is necessary to properly close the created defect, CPT® guidelines allows you to report the repair in addition to the excision. Note, however, that national Correct Coding Initiative (CCI) edits may prevent you from reporting intermediate or complex repairs with some benign lesion excision codes. Check CCI before reporting separate wound repair with benign lesion excisions.
Code range 11400-11446 excision codes are used to capture excision of benign skin lesions.
Code range 11600-11646 excision codes are used to capture excision of malignant skin lesions.
It’s also necessary to wait for the pathology report to accurately capture whether it is a malignant or benign lesion. If it is coded prior to pathology, it is always coded as a benign lesion with the unspecified diagnosis code. Do not use the uncertain behavior code, as this is also a pathologic diagnosis and cannot be reported prior to pathology support.
Open Communication Lines
If you have unclear language in the medical record, talk to your physician. The physician knows exactly what procedure was performed and the technique used, but may simply be unaware of any confusion from a coding perspective. Open communication and make recommendations for clearer documentation to create a smooth path to accurate service reporting and appropriate physician reimbursement.
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