I'm confused on how to code this lesion. Dr's note states:
On the L upper back there is a pigmented lesion which measures about .5 cm in diameter. It is irregularly pigmented. This area is prepped with betadine and infiltrated with a combination of Xylocaine, Bupivacaine and buffer. A 6mm disposable punch biopsy was used and this was carried down to the deep dermis. Specimen was entirely removed. The remainder of the dermis was excised and the skin was closed with 2 simple sutures of 4-0 nylon. Bleeding was well controlled. Specimen was sent to pathology. Wound care instructions are given. Sutures out in 7-10 days.
My question: Do I code a punch biopsy or an excision or both?
On the L upper back there is a pigmented lesion which measures about .5 cm in diameter. It is irregularly pigmented. This area is prepped with betadine and infiltrated with a combination of Xylocaine, Bupivacaine and buffer. A 6mm disposable punch biopsy was used and this was carried down to the deep dermis. Specimen was entirely removed. The remainder of the dermis was excised and the skin was closed with 2 simple sutures of 4-0 nylon. Bleeding was well controlled. Specimen was sent to pathology. Wound care instructions are given. Sutures out in 7-10 days.
My question: Do I code a punch biopsy or an excision or both?