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Thread: biopsy vs shave removal

  1. #1

    Default biopsy vs shave removal

    AAPC: Back to School
    I was hoping someone can explain this a little more to me..

    Here is how the note reads:
    Dark mole at R arm, changing; here for mole biopsy
    R arm: After the area was cleaned with betadine and alcohol swab, 2cc of Lidocaine was injected for anesthesia. Then mole biopsy was done with 5mm punch biopsy. After that the area was sutured with 3.0 Ethilon. For dressing, topical Abx, steri strips and bandage were used. Patient tolerated procedure well. Specimen sent to pathology. Instructions for care given. F/u in 10d for suture removal

    In the past I would have coded this as 11100, until looking thru the 2010 CPT book and it has a picture of punch biopsy under the description for 11300-11313 skin lesion removal:shaving

    In trying to find which would be appropriate I can across this explanation:
    If the intent is to identify the lesion and/or determine whether additional treatment is necessary, code 11100 would be appropriate, regardless of whether the lesion is completely or partially removed. If the intent is to remove the lesion, an excision or shave-removal code would be appropriate.

    Can someone please help clarify this? I think the more I read this, I am getting more confused.


  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    A shave is the removal of the entire anomoly partical thickness which means into the dermis. A biopsy is a removal of a piece of a lesion and can be either full or partial thickness. An excision is a removal of the entire anomoly full thickness which is through the dermis. A punch is a tool that always goes full thickness. If the punch takes the entire anomoly it is an excision, if it takes a piece the it is a biopsy. Looks to me like you have an excision.

    Debra A. Mitchell, MSPH, CPC-H

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