Biopsy CPT 11100 vs: 113xx

briannah

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hello, if anyone can help here, I'd greatly appreciate it. The verbiage on the note is as follows:
R. post. thigh: Procedure: Shave biopsy. We discussed the differential diagnosis with the patient and the importance of shave biopsy in facilitating diagnosis. Furthermore, I stressed that the information garnered from biopsy may help guide treatment. The patient fully understands that the lesion in question needs to be biopsied and neglecting biopsy of the lesion could delay or hinder successful treatment. The patient agreed to undergo shave biopsy. Verbal and written informed consent was obtained. Benefits, risks, side effects, and alternatives with the procedure were thoroughly reviewed. I specifically explained that there will be a scar following the procedure. Additional risks including pain, infection, and discoloration/pigmentary change were reviewed. The lesion in question was cleansed with an alcohol swab. It was then marked with a marking pen and the site was confirmed with the patient. Local anesthesia was then achieved using lidocaine diluted with epinephrine 1:100,000 (< 1.5 cc total volume used). The lesion was biopsied using a sterile dermablade. Hemostasis was easily achieved using pressure and aluminum chloride. The wound was dressed with vaseline and a bandage. Wound care instructions were carefully reviewed. The patient understands to apply vaseline and a bandage to the area daily until the wound heals. There were no complications. The specimen was sent to pathology. We will contact the patient with the biopsy results and arrange the appropriate follow-up.

Doctor used cpt 11100, insurance denied after reviewing the chart stating documentation does not support the charge. He also billed an excision but that was documented and coded separately. I advised the doctor based on the documentation he should have billed a 113xx code not the 11100. He thinks that is wrong.

Does anyone have any insight to this?

Thank You,
Brianna
 

thomas7331

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I agree with the physician that 11100 is the correct code. The 113xx codes are for shave excisions, which are intended for removal of the entire lesions. The documentation only indicates that this was a biopsy, and there is no indication that the provider removed the lesion completely. Although shaving was the technique used for the biopsy, it's still just a biopsy.
 
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I also agree with the physician, 11100.

The description of 11100 is "Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion" vs the description of codes 113xx begin with "Shaving of epidermal or dermal lesion,..."

Clearly the intent of the procedure was to take a biopsy, not to "remove" a lesion. Sure, 113xx matches the method stated, however it does not state the purpose - to obtain a biopsy. Since 11100 doesn't specify, or require, a certain method of how the biopsy was taken, it most accurately describes what was done.
 

LindaEV

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I also agree with the physician. Consider that they mean the documentation does not support the medical necessity of the charge. Was the excision you mentioned at a separate site? are they trying to bundle the two?
 
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