Excisional biopsy vs. excision


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SPECIMENS: Right posterior neck mass.

BRIEF OPERATIVE FINDINGS: Right posterior neck mass, 1.5 cm, completely excised.
INDICATIONS FOR PROCEDURE: seven-year-old male who presented for evaluation of a right posterior neck mass. This has been present for several years, intermittently enlarging and getting painful and tender. Exam was consistent with a neck mass, approximately 1 cm in size, in the subcutaneous/dermal planes. Ultrasound confirmed this lesion. Therefore, due to the patient’s chronic nature, the intermittent pain and discomfort, excisional biopsy was recommended to the family. The risks and benefits of this were discussed, which include, but are not limited to bleeding, infection, damage to local tissue, as well as anesthesia, and they elected to proceed.


The patient's bed was then rotated 90 degrees, and he was positioned for surgery. The right neck was facing out. Palpation of the right superior posterior neck demonstrated an approximately 1.5 cm firm mass associated with the subcutaneous plane and dermal layers. It was mobile in nature.

An elliptical incision was planned around the immediate skin edges and marked. This was infiltrated with 1% lidocaine with 1:1000 epinephrine solution. He was then prepped and draped in sterile fashion using ChloraPrep solution.

An elliptical incision was then performed, approximately 2 cm in total length. In the immediate subcutaneous plane, dissection was carried out with elevation of minor flaps. The lesion was then identified and dissection was then carried in a circumferential fashion along the posterior aspect of the mass without difficulty. It was noted to be adherent to some of the subcutaneous muscle, however, not infiltrative in nature. The specimen was placed in saline and then later formalin for a permanent pathologic evaluation

I billed 21555 because he totally excised the mass

Doc billed what was scheduled 21550 biopsy
my problem is biopsy is part of a lesion for diagnostic evaluation and pathology.
doc excised all the mass and said in his finding completely excised.. I need official docs saying that just because of the intent of the procedure isn't always what was done. other wise alot of docs would be out of some potential revenue....
any other opinions or help would be appreciated.


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Excisional biopsy vs. Excision

This is a different procedure, but the principle is the same. It is from CPT Assistant-Fall 1994:

Code 19101 describes a breast biopsy obtained through an incision. The physician makes an incision into the skin near the area of the lesion. The mass is visualized and a small piece of tissue (specimen) is removed. Many times, this specimen is examined immediately by frozen section. If the lesion is found to be malignant, another more extensive procedure may be performed at the same operative setting. If the entire lesion itself is removed (an “excisional biopsy”), code 19120 would be reported instead of 19101.
There are a lot of other citations with the same guidance but I thought you might want CPT Asst as a reference for your doctor.



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A biopsy is a procedure during which a sample of tissue is removed from a patient and examined under a microscope to aid in an accurate diagnosis. Before assigning a code for the procedure, the coder should read the entire operative note to verify the procedure performed. Sometimes the physician uses the term biopsy when a biopsy was not performed. If the physician documents excisional biopsy but removes an entire lesion, assign the code for the lesion excision. When only a portion of the lesion is excised, the biopsy code is assigned (AHA Coding Clinic for ICD-9-CM, 1990, second quarter, page 28).

Here is a link to another helpful article http://www.aafp.org/fpm/2005/1000/p47.html
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This can also help, page 88 CPT...These codes are chosen by greatest diameter, so if numbers are there with attention to excision. That is a safe indication to use the excision vs just biopsy.