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Diagnosis Code

  1. #1
    Question Diagnosis Code
    Medical Coding Books
    My dr. has performed a shave on a lesion, CPT 11300, with tissue to path. Path report comes back 173.5. Dr says we cannot assign 173.5 to a shave code. However, a shave is what in documented. Can we code 11100? Can a malignant diagnosis be coded with a shave procedure? Another senerio, the documentation states a "shave biopsy" was done, with tissue to path?

    What is the correct coding for these senerios?

    Thanks to all of you who respond.

  2. Smile Diagnosis code
    I think the reason for the procedure would determine the correct code. IF the reason for the procedure was "removal of the lesion" then 11300 would be appropriate, biopsy (11100) would not be reported separately. On the other hand, the reason for the procedure was to obtain the tissue to be sent to path, 11100 would be appropriate, shaving (11300) would not be reported separately. I hope this would help.

    Please find below the coding guideline on Biopsy as given in ICD - 9 - CM Manual:

    "During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of these procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported. The use of Biopsy procedure code (eg. 11100, 11101) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time."

    Please do correct me if I am wrong

  3. #3
    Thank you for the response. My real ? is, can we use a malignant ICD-9 code with a shave code? Ex. 173.5 with 11300?
    Last edited by csenn; 02-21-2011 at 05:59 PM.

  4. #4
    yes, you can use malignant dx code with a shave. we have encountered this before where our physician shaves off a lesion and it comes back malignant. at that point we would then perform another excision to confirm margins are clear.

  5. #5
    Columbia, MO
    AMA definition of:
    Biopsy - to remove only a piece of an anomly for study
    Shave - to remove the entire visible anomaly to a depth of partial thicknes: that is to the dermis, but not through it.
    Excision - To remove the entire visible anomaly to a depth of full thickness; that is through the dermis and to or into the subq layer.
    Yes code from the path report if that available for either the shave or bipsy codes. You hold the excision claims until the path is back with the diagnosis.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    I'd agree with Debra. We hold ours for path to come back also & often use a malignant DX (when appropriate of course )

  7. #7
    Thank you for the information. I will pass it along.

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