Biopsy coding in 2019: Part 2
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, December 3, 2018
New, technique-specific biopsy codes 11102-11107 will replace the existing 11100 and 11101 biopsy codes on Jan. 1.
I bet that you noticed that a tangential technique can be used for both a tangential skin biopsy and a shave removal procedure. How would you determine which is most appropriate to report? Incisional biopsy and an excisional removal of a lesion: How do they differ? What are the specific qualifications for a punch biopsy? The tables below will assist you in selecting an optimal code.
Example 1: You do a full-thickness punch biopsy of the vermilion of the lip. You code CPT 11106 for the biopsy.
Answer: Incorrect. The new integumentary biopsy codes are defined for skin only. For mucosal biopsies, including the lip vermilion, one should select an appropriate site-specific code, in this case, CPT 40490, biopsy of lip.
Example 2: You do a punch biopsy of a lesion on the nasal tip. There is no fat attached to the base of the biopsy, although you are sure that you penetrated through the dermis. As there is no fat attached, you are now uncertain: Should you report this as a punch biopsy, 11104, or a tangential biopsy, 11102?
Answer: A punch biopsy. 11104. A punch biopsy is done full-thickness, through the dermis. The CPT® states that the punch must penetrate deep into the dermis, into the subcutaneous space. However, visible attachment of subcutaneous tissue, such as fat, is not stipulated. Consequently, CPT 11104, punch biopsy is the correct code.
Example 3: Suspecting a deeply penetrating tumor such as a dermatofibrosarcoma protuberans, you do a wide and long incisional, fusiform, full-thickness sampling of the lesion down to fascia. Due to the resistance of the wound edges to closure you do a layered repair of the defect. You code CPT 11106 for the incisional biopsy and an appropriate intermediate repair CPT code.
Answer: Correct. The intent was to sample both skin and deep subcutaneous tissue. This meets the definition of an incisional biopsy. The incisional biopsy (and punch biopsy) includes (but does not require) simple closure. However, when in addition to simple closure a layered repair is indicated, then an appropriate repair code may be reported.
Example 4: An established patient complains to you of a cheek mole that repeatedly bleeds and swells after he runs his shaving blade over it. You identify a dome-shaped, focally crusted tan-brown smooth, symmetrical 4 mm wide papule consistent with an irritated nevus. You remove it via the tangential shave technique and submit it for histopathologic evaluation. You sent the specimen to histopathology. Should you report your procedure as a tangential biopsy, CPT 11102, or a shave removal, CPT 11310?
Answer: Shave removal. There was no suspicion of atypia. Rather, the nevus was removed to make the patient more comfortable and happier. Consequently, this was a therapeutic, rather than a diagnostic, procedure. CPT 11310, shave removal, cheek, 0.5 cm diameter or less, is correct.
Example 5: During a complete skin examination of a patient with dysplastic nevi you identify a 1.2 cm wide pigmented patch suspicious for a melanoma. You proceed to do a full-thickness, into subcutaneous fat removal of the lesion with 3 mm clinical margins. You select CPT 11602, excision, trunk, 1.1-2.0 cm diameter, as the histopathology confirmed a melanoma.
Answer: Correct. Your intent was to diagnose the lesion with a full thickness excision (removal) with margins. This meets the definition of an excision. An incisional biopsy is a sampling of a lesion, which implies a partial removal and/or an absence of intent to remove a lesion full-thickness, with margins. The corollary of this is that an incisional biopsy code, 11106, is inappropriate. This procedure should be reported or adjudicated as an excision.
