Shave removals
Shave removals: In a nutshell
- Shave removal codes are used for either benign or malignant lesions.
- The shave does not extend beyond the dermis.
- Either the entire lesion or only the noxious portion of the lesion is removed.
- Incidental pathology of the tissue removed may be performed.
Shave removal can be reported to remove benign or malignant lesions. Report the shave using the size of the lesion itself, measured prior to the procedure.
At times, deciding whether to use a shave code can prove more complex. Just because you use a shave technique doesn’t mean you should use a shave code. If the shave technique is purposely deeper, beyond the dermis, you will need to code it as an excision.
Shave codes can also be complicated when it comes to pathology. Shaves can be used for pathology purposes, but it’s not a requirement. If you remove a portion of the skin (remaining inside the dermis), and then decide to perform a histopathologic examination incidental to the removal, a shave code is most appropriate.
Lesions of the trunk, arms, or legs
| CPT Code | Defined by size of tissue removed | Coding rule |
|---|---|---|
11300 |
0.5 cm or less |
Each code represents a single lesion, do not add the size of multiple lesions together. Report a separate code for each lesion treated during the encounter. Modifier 59 should be appended to each additional lesion excised. |
11301 |
0.6 to 1.0 cm |
|
11302 |
1.1 to 2.0 cm |
|
11303 |
Over 2.0 cm |
Lesions of scalp, neck, hands, feet, or genitalia
| CPT Code | Defined by size of tissue removed | Coding rule |
|---|---|---|
11305 |
0.5 cm or less |
Each code represents a single lesion, do not add the size of multiple lesions together. Report a separate code for each lesion treated during the encounter. Modifier 59 should be appended to each additional lesion excised. |
11306 |
0.6 to 1.0 cm |
|
11307 |
1.1 to 2.0 cm |
|
11308 |
Over 2.0 cm |
Lesions of face, ears, eyelids, nose, lips, or mucous membrane
| CPT Code | Defined by size of tissue removed | Coding rule |
|---|---|---|
11310 |
0.5 cm or less |
Each code represents a single lesion, do not add the size of multiple lesions together. Report a separate code for each lesion treated during the encounter. Modifier 59 should be appended to each additional lesion excised. |
11311 |
0.6 to 1.0 cm |
|
11312 |
1.1 to 2.0 cm |
|
11313 |
Over 2.0 cm |
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