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When Billing for Biopsy Services, Do This, Not That

When Billing for Biopsy Services, Do This, Not That

MAC clarifies billing and coding policy for CPT® codes 11102-11107.

Six new CPT® codes in the 111xx range were added in 2019 to describe tangential, punch, and incisional biopsy techniques. Since then, First Coast Service Options, Inc. (FCSO) reports an uptick in biopsy claims being denied. What gives? According to this Medicare Administrative Contractor (MAC), there are things you should and shouldn’t do when billing these biopsy services.

Dissect the Codes

The surgical codes in question are:

11102    Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion

+11103  each separate/additional lesion (List separately in addition to code for primary procedure)

11104    Punch biopsy of skin [including simple closure, when performed]; single lesion

+11105  each separate/additional lesion (List separately in addition to code for primary procedure)

11106    Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); single lesion

+11107  each separate/additional lesion (List separately in addition to code for primary procedure)

CPT® 11102 and +11103 describe tangential biopsy: The first code describes biopsy of a single lesion, and the second add-on code describes each additional lesion biopsied beyond the first. A tangential biopsy is performed with a sharp blade to remove a sample of epidermal tissue, which may include some underlying dermis.

CPT® 11104 and +11105 describe punch biopsy: The first code describes biopsy of a single lesion, and the second add-on code describes each additional lesion biopsied. This type of biopsy requires a punch tool to remove a full-thickness cylindrical sample of skin and includes simple closure of the defect.

CPT® 11106 and +11107 describe incisional biopsy: The first code describes biopsy of an initial lesion, and the second add-on code describes additional lesions. Incisional biopsy is performed using a sharp blade to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating deep to the dermis, into the subcutaneous space.

Do This, Not That

A clue to what is causing some claims to be denied can be found in the CPT® guidelines: Use of the incisional, punch, and tangential biopsy codes indicates that the procedure was to obtain tissue for “diagnostic histopathologic examination” and that the procedure was “performed independently or was unrelated or distinct from other procedures/services provided at that time.”

1. Report 11102-11107 for diagnostic biopsies only. Do not bill these biopsy codes with a screening diagnosis code.

Append the appropriate modifier to the appropriate code. When billing a biopsy code with other unrelated surgery codes on the same date of service, append modifier 59 Distinct procedural service (or the appropriate X{EPSU} modifier) to the biopsy code, when applicable, not the surgery code. If you append the modifier to the wrong code, you will get a denial reason code CO236.

TIP: Check the appropriate version of National Correct Coding Initiative Procedure-to-Procedure (NCCI PTP) edits for when a modifier is allowed. A modifier is generally allowed (modifier indicator 1) when the biopsy is billed secondary to a major procedure, as shown in Table A, but very often not allowed (0 modifier indicator) when billed primary to a surgical procedure, as shown in Table B.

2. Similarly, make sure to report the correct primary code.

3. These biopsy codes may be “mixed and matched” to report biopsy of numerous lesions by various methods (e.g., incisional biopsy of an initial lesion, tangential biopsy of a second lesion). A table was added to the CPT® guidelines in 2019 to help with coding multiple biopsies.

However, check the Centers for Medicare & Medicaid Services’ Medically Unlikely Edits (MUEs) to make sure you are not exceeding the maximum units of service that a provider may report for a single patient on a single date of service. For 11102, 11104, and 11106, you may bill one unit per line item. For 11103, 11105, and 11107, you may submit multiple units on a single line item, as shown in Table C.

According to FCSO, this will prevent duplicate denials. “The system will allow the first line without a modifier and the second line with the appropriate modifier, then will deny subsequent lines as an exact/suspected duplicate,” FCSO states on its website (billing news, updated March 14).

Take these three steps when billing CPT® codes 11102-11107 to receive proper payment from Medicare in a timely manner.


Resources:

https://medicare.fcso.com/Billing_news/0431797.asp

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Renee Dustman
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About Has 737 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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