Dermatology Coding Alert

Published on Tue Jan 26, 2010 PDF

Question: A patient comes to the office with a 1.1 cm raised brown nevus on the middle, upper portion of her back that rubs on her bra. The dermatologist removes it using a shave technique. The pathology report indicates a benign compound nevus. The lateral and underlying dermal margins are clear, confirming complete removal of the nevus. How should I report this procedure?

Delaware Subscriber

Answer: Report 11302 (Shave removal benign lesion trunk, 1.1-2.0 cm). Even if the dermatologist completely removed the nevus, do not bill an excision code.

Reason: A shave removal is a distinct procedure, intended to remove a lesion or the problematic portion of the lesion. The removal of the lesion by the shave technique requires a more superficial procedure than an excision in the integumentary system, but typically does not require complete removal of the lesion. Thus, only the shave removal code would be reported. Another indicator that will tell you the difference between the shave technique and excision is how deep into the skin the removal goes. Shave removal does not involve the full thickness of the dermis, whereas excision codes require removal of the entire thickness of the dermis through to the subcutaneous tissue.