Biopsy coding in 2019: Part 1
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, November 1, 2018
Dermatologists commonly biopsy skin lesions via a tangential shave technique, with a punch, or with a scalpel incision to extract an optimal tissue specimen for histologic evaluation. Have you ever wondered why these diverse techniques — requiring different supplies and procedures — are all commingled under one CPT® biopsy code, 11100? Wonder no more! The biopsy codes are changing for 2019. The long-established codes, 11100 and 11101, will be deleted and invalid as of Jan. 1, 2019. They will be replaced with procedure-specific codes based upon the biopsy technique: tangential, punch, and incisional. There will be no transitional grace period: Coding with CPT 11100 and 11101 in 2019 will result in non-payment. So, it is imperative that the new codes are understood, activated within your billing system, and implemented on Jan. 1.
Unlike the existing integumentary biopsy codes, which include mucous membrane biopsies, the new codes are limited only to integumentary (skin) biopsy procedures. So, what happens if you biopsy a mucosal surface? Well, the existing site-specific biopsy codes, including those for mucosal surfaces such as lip vermilion, will be preserved unchanged and available for use.
The new, technique-specific biopsy codes will follow existing integumentary biopsy coding convention, specifying a primary code for the first biopsy and an add-on code for each additional biopsy. The table below defines the new codes as well as the codes to be deleted, for comparison.
The 2019 CPT lists specific qualifying criteria for each of the new codes.
- Intent: Extract a sample of a lesion or lesions for diagnostic histopathologic examination.
- Technique selection: Technique selected based upon which would optimally present tissue for histopathologic evaluation.
- Technique descriptions: Listed in the following table.
- Multiple biopsies done on the same day: Same-day biopsies done on different lesions or different sites may be reported separately
- Exclusion criteria: Stratum corneum sampling only such as via a skin scraping or tape stripping is not separately reportable, as this does not constitute a biopsy.
Coding for multiple biopsies
Just as with the soon to be deleted 11100 and 11101 codes, only one primary biopsy code may be reported. Additional biopsies are specified by their pertinent add-on codes. However, there are now three sets of primary and three sets of add-on codes. When doing multiple biopsies utilizing more than one technique, which primary code should you choose?
There is a simple hierarchy to primary code selection:
Incisional biopsy (11106) > Punch biopsy (11104) > Tangential biopsy (11102)
When doing multiple biopsies utilizing the same technique, such as punch biopsies, for example, one would report one primary code, 11104 and multiples of the add-on code, 11105 x number of additional biopsies.
When doing multiple biopsies involving more than one biopsy technique, code selection will adhere to the above hierarchical guideline. Whenever an incisional biopsy is done, it is always reported with its primary code (11106) and all other biopsy modalities are reported with add-on codes (punch biopsy: +11105, tangential biopsy: +11103). When punch and tangential biopsies are done, the punch biopsy is reported with a primary code (11104) and any additional punch and tangential biopsies are reported with add-on codes (+11105, +11103).
The following illustrates six biopsy coding scenarios:
-
Three tangential biopsies coded as:
First: 11102
Second: 11103
Third: 11103
-
Two punch biopsies coded as:
First: 11104
Second: 11105 -
One punch, two tangential biopsies coded as:
Punch: 11104
Tangential 1: 11103
Tangential 2: 11103 -
Three incisional biopsies coded as:
First: 11106
Second: 11107
Third: 11107 -
One incisional, two punch biopsies coded as:
Incisional: 11106
Punch 1: 11105
Punch 2: 11105 -
One incisional, one punch, two tangential biopsies coded as:
Incisional: 11106
Punch: 11105
Tangential 1: 11103
Tangential 2: 11103
Okay, then, you have conceptualized and implemented the new skin biopsy codes. What if you are doing a biopsy of mucosal tissue? What is the code for that? Below is a table of all of the available site-specific biopsy codes. Their definitions remain unchanged. Site-specific biopsy codes are technique agnostic. Only the location, and not the biopsy technique, determines the appropriate code.
What next? Ensure that your electronic health records and office management programs will be updated to process the new codes appropriately, and that the old codes are rendered useless on Jan. 1, 2019.
