Biopsy, excision, shave, and destruction codes

Properly coding biopsies or removals of lesions can be confusing. The intent and technique you use for treating a lesion can make a difference when it comes to your choice of codes. Being specific is critical when it comes to coding. 

What exactly are the differences between these procedures, and where do you need to be especially careful?

Biopsies

Classifying a procedure as a biopsy is based on your intent.

• Biopsy codes should only be used if your intent is to sample the lesion for histopathologic examination.

• The tissue sample may include all or a portion of the lesion.

• Skin biopsy procedures are listed based on the technique used to obtain the tissue sample.

Destructions

A destruction is the ablation of benign, premalignant, or malignant lesions by any method — well, almost any method.

• Destructions can use curettage, electrosurgery, cyrosurgery, or laser or chemical treatments. The key word here is ablation. Destructions do not include removal by means of a blade or surgical scissors.

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Excisions

There are two significant ways excisions are different than biopsies.

• In an excision, you remove the entire lesion, not just a sample. A biopsy is only a sample of tissue, though in some circumstance the tissue obtained for sampling may include the whole lesion.

• Excision codes are intended for therapeutic treatment, not for diagnostic purposes. If your intent is to obtain a tissue sample for diagnostic purposes, it should be reported with incisional biopsy codes.

Shaves

A shave removal code should be used when the primary purpose is removal.

• Use a shave code when the entire lesion or the noxious part of the lesion is removed by shave technique using a scalpel, flexible blade, or curette. Tissue removed is contained to the dermis. 

• The tissue removed can be used for incidental histopathologic examination, if the intent remains removal by shave technique.

If you use a shave technique, but your initial intent is to sample a portion of the lesion, you should actually report it as a tangential biopsy of the skin. 

Can they go together?

Dermatologists constantly provide more than one service in a single appointment, and biopsies are often in the mix. 

In the realm of coding, biopsies have their own set of rules. There are certain times when you can bill a biopsy and other services — such as shaves, excisions, or destructions — separately, and other times when you cannot. 

The general rule of thumb is that you can only bill for a biopsy in conjunction with another procedure if it relates to a distinct and separate lesion on the same date of service.

For example, let’s say you sample a portion of a suspected basal cell carcinoma using a shave technique, then curette the base of the lesion and send the specimen to the lab. Since there was only one lesion, you can’t bill for a shave, biopsy, and destruction all at once. 

Remember, classifying a procedure is based on your intent. In this case your intent was to obtain a tissue sample to submit for histopathologic examination. While at it, you decided to curette the base of the lesion which cannot not be reported as a separate destruction. You would report a tangential biopsy and neoplasm of uncertain behavior as your diagnosis code. 

Just remember that whenever you bill separately for procedures performed at the same visit, use modifier 59. If you don’t, the insurance carrier may assume that the biopsy was part of another procedure. This will result in them bundling the biopsy service into the procedure, and denying separate payment for the biopsy. 

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