Dermatology Coding Alert

3 case examples to test your knowledge of 11100-11600

Test your biopsy and excision skills with operative notes. See if you know how to code the following three procedures:

Hint: Look for complete versus partial removal of the lesion.

Procedure 1: Patient presents with a raised, suspicious-appearing, 2-mm lesion on her right arm. The dermatologist completely removes the lesion using a 3-mm punch excisional tool and closes the surgery site with one 4-0 ethilon suture.

Procedure 2: Adermatologist examines a very dark brown, multicolored, irregular-shaped 3-mm lesion on a patient's right medial shoulder. She uses a 4-mm punch excision tool to remove the lesion to full thickness. She then closes the site with two 4-0 ethilon sutures in a simple interrupted fashion.

Procedure 3: Apatient points out some rough skin on her right lateral shoulder. Because she says the area looks similar to squamous cell carcinoma that she previously had, the dermatologist takes a 3-mm punch biopsy of the tissue. He then closes the site with one 4-0 ethilon suture in a simple interrupted fashion.

Now take a look at the coding solutions for these three case examples.

Coding solution 1: In this case, the dermatologist removes the entire lesion. Therefore, you should report excision code 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) or 11600 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less) depending on the pathology report. Excision includes simple closure, so don't separately report the suture.

Coding solution 2: You should report 11400 for a benign lesion excision or 11600 for a malignant lesion excision. The dermatologist takes the entire lesion to the defined depth (full thickness) an excision requires.

Coding solution 3: Here, you should use the biopsy code (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). The dermatologist takes the tissue sample to obtain a diagnosis, not to remove the entire lesion.

Note: Examples and coding explanations provided by Shari Aloway, CPC, coding specialist from Flowertown Physicians in Summerville, S.C.