Dermatology Coding Alert

Published on Mon Jul 25, 2016 PDF

Question: When our dermatologist performs shaving or excision of a lesion, should we take into account only the size of the lesion that was removed or should we also consider the amount of normal tissue margins that were removed with the lesion?

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Answer: When your dermatologist performs a shave of a lesion, you should only consider the size of the lesion that was removed. Any extra margins that your clinician removed along with the lesion should not be taken into account to arrive at the code to be reported.

For instance, if your dermatologist shaved an 0.8 cm benign lesion on the foot, and removed a 0.4 cm margin along with the lesion, you should not add up the size of the lesion with the margin removed to report 11307 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm). Instead, you should only consider the size of the lesion and report 11306 (…lesion diameter 0.6 to 1.0 cm). This is because the code descriptor explicitly refers to “lesion diameter” only.

However, when reporting an excision, you should also take into account the margin removed along with the lesion to arrive at the code to report. So, if the lesion and the margins that were excised were similar to the shaving instance mentioned above, you will report 11422 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) considering the size of the lesion and margins removed and not 11421 (…excised diameter 0.6 to 1.0 cm) taking into consideration only the size of the lesion. As indicated, the code descriptors for lesion excision explicitly refer to “lesion including margins” and not just the lesion diameter.