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electrosurgery w/ shave removal

  1. #1
    Question electrosurgery w/ shave removal
    Medical Coding Books
    I work at a family practice office and I have one physician that does a lot of lesion removals. I just spoke with a coder at a local dematology office but want a little more clarification.
    Here is an example of one of his dictations for a recent lesion removal:

    "....A shave biopsy was taken and then extensivelly cauterized then curetted fairly aggresively. There is a central split extending deeper in the center of that. I was able to curette down to an apparently cancer-free base with no more friable tissue identified. We will send this to pathology. The lesion size was 2cm X 1cm."

    Ok, so here is my question. The pathology result came back with diagnosis of Actinic Keratosis. Would I code this as 11302 for shave or do I charge 17000 for destruction of benign lesion? If this were to have come back as being a carcinoma would I have charged as a shave or as a destruction of malignant lesion?

    Thanks for your help!!

  2. #2
    Columbia, MO
    I would say this is a shave regardless of the pathology. The definition of shave is partial thickness removal of the entire lesion. This is what it appears he did.

    Debra A. Mitchell, MSPH, CPC-H

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