General Surgery Coding Alert

Look beyond integumentary codes for specific tissues.

A skin biopsy is a skin biopsy is an 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) -- right?

Not necessarily. In fact, CPT® provides multiple site-specific biopsy codes for external lesions that you can report instead of 11100, in some circumstances. Let us help you learn how to pick the proper code and save your general surgery practice up to $112 per lesion.

Check Out 'Unless Otherwise Listed'

You'll notice that the 11100 code definition states "unless otherwise listed." That means you should not use 11100 if your surgeon takes a skin biopsy from a specific site that's listed elsewhere in CPT®.

For example: If your surgeon performs a biopsy on a lip lesion, you should report 40490 (Biopsy of lip) instead of 11100. As long as the surgeon notes the site-specific biopsy in the documentation, you should receive $26 more for the procedure on the patient's lip than if you had reported 11100 (based on non-facility national amounts, conversion factor 34.0376).

That's because the lip biopsy requires more work, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. For instance, the surgeon might take extra steps for a lip biopsy, including the use of a chalazion clamp to control bleeding.

Table 1 lists other codes you might consider instead of 11100 when your surgeon excises a skin lesion from a specific site.

Understand Complexity

CPT® provides site-specific biopsy codes for certain integumentary specimens because they represent varying levels of work, and you need to ensure that you report your general surgeon's services accordingly.

In a communication on skin biopsy coding guidelines, CPT® Assistant (Oct. 2004) states, "The complexity of the biopsy procedure may vary significantly for different anatomical portions of the body. In consideration of this, the CPT® coding system includes site-specific codes for a biopsy of select body areas. To conform to CPT® guidelines that the most specific code should be used to identify a given service, code 11100 is to be used if no site-specific code is available."

For instance: If a surgeon performs an incisional biopsy of the eyelid that includes the lid margin, you should list 67810 according to Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

Eyelid biopsies often involve the lid margin, tarsal plate, or palpebral conjunctiva, which makes the procedure more complex than the general integumentary biopsy that you'd report as 11100.

Tip: Make sure coders in your office are familiar with Table 1 to ensure accurate skin biopsy coding, and in most cases, to legitimately increase pay for your surgeon's services.

Avoid Excision Confusion

Another coding pitfall that could cost your surgeon rightful pay is using skin biopsy codes to report skin lesion excision.

If your surgeon intends to remove the entire lesion leaving "clear" margins, you should select an excision code instead of a biopsy code. The excision codes are site-specific and sometimes diagnosis dependent, and commonly pay significantly more than a skin biopsy.

For instance: If your surgeon excises a 1.5 cm lesion from a patient's forehead, you have two code choices, depending on the diagnosis:

• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm), which pays $187.55
• 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm), which pays $ $271.62.

Erroneously reporting the skin lesion excision as a skin biopsy (11100, $103.81) could cost you plenty -- $83.74 for a benign lesion excision or $167.81 for a malignant lesion excision. (All values based on PFS non-facility national amount, conversion factor 34.0376.)

Follow CPT® Assistant: The Oct. 2004 article helps distinguish skin biopsy versus skin excision like this:

"The intent of a biopsy is to remove a portion of skin, [or] suspect lesion ... so that it can be examined pathologically." In contrast, "The intent of other integumentary system procedures that involve removal of tissue is ... for the purpose of removing an entire lesion."