Wiki skin biopsy

[aaseals32]

Can someone tell me if this is a 11104 or 11401

Procedure

Sterile prep performed macular brown lesion mid back
Injection 1 cc 2% lidocaine with epinephrine locally to lesion
Elliptical excision 2 x 5 mm performed on the superior lateral margin of the lesion in question. Specimen sent to pathology. Wound closed using 2 interrupted 4-0 Ethilon sutures. Procedure tolerated well without complication.

Chief Complaint

Here for biopsy of abnormal skin lesion

History of Present Illness

Abnormal skin lesion on back identified at annual wellness visit. Has been present for at least a year. Uncertain if any change. No history of skin cancer.

Physical Exam

Skin
Examination of the skin for lesions: Abnormal. Mid back just right of midline 10 x 12 mm brown macule. Symmetric with uniform coloring however has fried egg appearance margins on the superior and right lateral region.

Pathology report
Material submitted: DERM, BACK - Skin, Mid Back, Biopsy:
Diagnosis: COMPOUND DYSPLASTIC NEVUS WITH MILD ATYPIA, INVOLVING THE PERIPHERAL BIOPSY MARGIN.

Gross description: .
Received in formalin labeled with patient's name and date
of birth, mid back is a 0.6 x 0.3 cm tan, elliptical
fragment with a variegated brown, raised surface. The
specimen is inked orange, bisected, and submitted in toto
in 1 cassette. Grossing tech: GFI

Pathologist provided ICD-10:
D48.5

 

[thomas7331]

Can someone tell me if this is a 11104 or 11401

Procedure

Sterile prep performed macular brown lesion mid back
Injection 1 cc 2% lidocaine with epinephrine locally to lesion
Elliptical excision 2 x 5 mm performed on the superior lateral margin of the lesion in question. Specimen sent to pathology. Wound closed using 2 interrupted 4-0 Ethilon sutures. Procedure tolerated well without complication.

Chief Complaint

Here for biopsy of abnormal skin lesion

History of Present Illness

Abnormal skin lesion on back identified at annual wellness visit. Has been present for at least a year. Uncertain if any change. No history of skin cancer.

Physical Exam

Skin
Examination of the skin for lesions: Abnormal. Mid back just right of midline 10 x 12 mm brown macule. Symmetric with uniform coloring however has fried egg appearance margins on the superior and right lateral region.

Pathology report
Material submitted: DERM, BACK - Skin, Mid Back, Biopsy:
Diagnosis: COMPOUND DYSPLASTIC NEVUS WITH MILD ATYPIA, INVOLVING THE PERIPHERAL BIOPSY MARGIN.

Gross description: .
Received in formalin labeled with patient's name and date
of birth, mid back is a 0.6 x 0.3 cm tan, elliptical
fragment with a variegated brown, raised surface. The
specimen is inked orange, bisected, and submitted in toto
in 1 cassette. Grossing tech: GFI

Pathologist provided ICD-10:
D48.5

I would code this as a biopsy since only a portion of the lesion was removed. The intent of the procedure is to biopsy, not to excise, and you can also tell from the measurement that the provider did not attempt to remove the entire lesion. The technique is incisional, not punch, so 11106 would be correct here, not 11104.

 

[aaseals32]

I would code this as a biopsy since only a portion of the lesion was removed. The intent of the procedure is to biopsy, not to excise, and you can also tell from the measurement that the provider did not attempt to remove the entire lesion. The technique is incisional, not punch, so 11106 would be correct here, not 11104.

Thank you