Code This Lesion Excision as a Biopsy
Question: Our otolaryngologist examined a patient and found a 2.8 cm white lesion with a slightly ulcerated surface on the lateral border of the posterior third of the patient’s tongue. The tissue surrounding the lesion looked normal. After numbing the area, the surgeon used a scalpel for sharp removal of a 7 mm portion of the ulcerated lesion, closing the site with two sutures. My question is this: As the surgeon closed the site, should this encounter be coded as an excision, especially since the word “biopsy” does not appear in the op note? Revenue Cycle Insider Subscriber Answer: The fact the surgeon closed the wound site does not mean you should use an excision code such as 41113 (Excision of lesion of tongue with closure; posterior one-third). This is because the note tells you the surgeon only removed a 7 mm section of the 2.8 cm lesion. Removal of an entire lesion is classified as an excision per CPTÒ, whereas CPTÒ regards removal of part of a lesion as a biopsy, regardless of whether the surgeon closes the wound after the tissue is removed or not. This means looking to the biopsy codes, which are divided into anterior (the front two-thirds), coded to 41100 (Biopsy of tongue; anterior two-thirds); and posterior (the back third), coded to 41105 (... posterior one-third). As the note specifically states the lesion is in the posterior third of the patient’s tongue, the correct coding for this encounter would be 41105. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
