General Surgery Coding Alert

Question: Our surgeon obtained a partial incisional biopsy followed by excision of the same lesion. Should I report the biopsy, the excision, or both?

Oregon Subscriber Answer: Generally, biopsy is included in excision of the same lesion, but it's easy to get confused. To sort through the confusion, follow three basic rules:
 
1. If the surgeon performs incisional biopsy on a lesion or lesions, but does not remove any lesions completely, claim only the biopsy(s).
 
2. If the surgeon performs incisional biopsy on a lesion or lesions and follows by excising the remainder of the lesion(s) immediately (as in the case you cite), report only the excision.
 
3. If the surgeon biopsies a lesion but completely excises a different lesion, you may report both the biopsy and lesion codes, as appropriate, with no modifiers, as long as the descriptor for the excision does not included the phrase "with or without biopsy."
 
Note: CPT 2004 contains new language in an explanatory paragraph preceding the biopsy codes that clarifies the above points. For more information, see General Surgery Coding Alert, January 2004.  - Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.