Year: 2004 CPT ASST
Title: Skin Biopsy Coding Guidelines (October 2004)
Body: Coding Communication:Skin Biopsy Coding Guidelines
Coding guidelines require that the assignment of codes be based upon physician documentation. When the procedure note or report title and narrative indicate biopsy(ies) was performed, the appropriate biopsy code(s) may be reported as long as they are consistent with the previously quoted biopsy guidelines and the content of the CPT code descriptor. Similarly, when the procedure documentation supports another integumentary system procedure such as shave removal, destruction, or excision of a lesion, the appropriate code for the documented procedure should be reported.
Common Sources of Confusion
Four common areas of confusion and the methods to resolve them are described in the following list.
A biopsy is the pathological examination of a specimen. This concept and variations of it create the impression that any procedure in which the specimen is sent to pathology is a biopsy. Based on the prior discussion about biopsies, that conclusion is erroneous. The biopsy guidelines and previous examples provide clarification needed to avoid inappropriate coding.
The term biopsy can be used as a generic description for surgical procedures on the skin. Because the term biopsy is better understood by patients than the term excision or shave removal, it has occasionally been used to describe those nonbiopsy procedures. Colloquially, patients understand that biopsies are used to determine whether a lesion is malignant. They also understand that biopsies are sent for pathological examination. It is easy to default to colloquial language that, while better understood by patients, fails to be explicit enough for coding purposes. This practice of using such language can eventually cross over into coding and cause inevitable confusion. If used frequently, the lines among these concepts blur and may lead to “mixed” documentation (see the next point of confusion). The solution: refer to the preceding guideline explanations and use proper medical terminology at all times in each context. Doing so provides an additional benefit to patients who learn the correct use of medical terms and derive additional specific information about the procedures performed.
It is acceptable if documentation mentions both biopsy and excision for a procedure on the same lesion. If necessary, the physician may need to clarify which procedure was performed. An addendum may be necessary. In these situations, only a single code may be reported for the procedure. If the procedure narrative describes excision, the appropriate code that supports the documented method used for excision should be selected. If the documentation supports a biopsy, the appropriate code(s) from 11100- 11101 should be reported.
The complexity of the biopsy procedure may vary significantly for different anatomical portions of the body. In consideration of this, the CPT coding system includes site-specific codes for a biopsy of select body areas. To conform to CPT guidelines that the most specific code should be used to identify a given service, code 11100 is to be used if no site-specific code is available.
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