Part B Insider (Multispecialty) Coding Alert

Published on Wed Oct 12, 2005 PDF

Sometimes a "punch biopsy" isn't really a biopsy

Don't bill for a biopsy when your physician goes to all the trouble of removing a lesion completely--or your doctor's work will go unrewarded.

You can easily mistake a lesion excision for a biopsy because when your physician removes a lesion, he or she will usually send a sample of the lesion for a biopsy afterward. But a biopsy refers only to removing part of the lesion for testing, not the whole thing, including margins, says Carrie Ontiveros, coding specialist with the Wichita Clinic in Wichita, KS.

"I get a lot of questions about this," says Linda Martien with National Healthcare Review in Woodland Hills, CA. Many physicians who have excised lesions "may be under the impression that because they're sending [a sample] for a biopsy, that's what they should bill."

In 2006, lesion biopsy code 11000 will pay only 1.25 RVUs in the non-facility setting. By contrast, lesion excision codes 11400-11646 will pay anywhere from 2.91 RVUs to 12.32 RVUs, depending on the site and size of the lesion. The reimbursement almost doubles for malignant lesions because of the added risk, says Ontiveros.

What to do: Look for coding clues in the medical record. 11000 involves biopsy of skin, subcutaneous and/or mucous membranes, plus simple closure, says Ontiveros. Typically, this just involves shaving the lesion, which may not even require closure.

Even if your physicians simply mention biopsy in the record, you can tell if they excised the whole lesion by looking for details such as the number and type of sutures, the size and diameter of the lesion, how deep the incision went, and so on, says Martien.

Watch out: There are some exceptions. For example, your physician may perform an "excisional biopsy," especially with a breast lesion, says Ontiveros. An "excisional biopsy" means removing the whole lesion. A "punch biopsy" may also refer to removal of the whole lesion.

Sometimes with terms like "excisional biopsy," you have no choice but to query the physician as to what the procedure involved, says Martien.