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biopsy Code

  1. Default biopsy Code
    Medical Coding Books
    I am not sure which BX code to use for the following coding scenario. Can someone help me with the following scenario?

    Procedure-Biopsy of mass RT groin
    The physician did an incisional biopsy. Dissection was carried down through the skin and subQ tissues. Scarpa fascia was divided.. A portion of the large mass was excised using sharp dissection. The sub Q tissues were approximated using interrupted sutures. The skin was closed using subcuticular suture.

    The codes I was contemplating on using was 49180, but in the CDR description, it says no incision was necessay. In the OP report, he did a skin incision. The other code was 11100, there is no mention of an incision. (says surgically removes, may be done with a scapel)


  2. #2

    I use 27040 and 27041 depending on the depth of the biopsy.


  3. #3
    Milwaukee WI
    Default 27040-41
    I agree with RainyDaze ... 27040 or 27041 depending on depth.
    Based on what you provided, the surgeon did go into the fascia, so I'd probably use 27041.

    F Tessa Bartels, CPC, CPC-E/M

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