FAQs

Question: When reporting additional biopsies beyond the MUE limit, how should charges be submitted?

Answer: Services that exceed the MUE limit can be submitted in the same manner by which regular claims (those within MUE limits) are submitted. The difference between the two submission will be that the units beyond the MUE limits will usually be denied and a redetermination with medical records to justify the medical necessity will be submitted for consideration.

For example:

Four incisional biopsies reported as 11106; 11107 x2; 11107-76

Note: Incisional biopsy, additional lesion CPT code 11107 has a date of service MUE of 2; the use of modifier 76 will not circumvent the claim-edit denial.

In this case, the third unit will have to be appealed with medical records to support the medical necessity for the extra biopsy performed. Therefore, be prepared to appeal for the additional units of the MUE

Question: Patient presents with a biopsy-proven basal cell carcinoma (BCC). Physician uses a punch instrument to excise the lesion. Should this be coded as an excision (code 116XX) or punch biopsy (code 11104)?

CMS

These changes are expected to help increase transparency, clarity, consistency, reduce provider burden and enhance public relations while retaining the ability to be responsive to local clinical and coverage policy concerns

Answer: It is important to note that the new skin biopsy codes are selected and reported based on the intent of the procedure. In order to report the skin biopsy code, the provider has to indicate that:

• The intent of the procedure was

   solely to obtain tissue for diagnostic histopathologic examination; and

• The procedure was performed independently or was unrelated and distinct from other procedures/services provided during the same encounter.

Note that malignant lesion excision is defined as full-thickness (through the dermis) removal of a lesion including margins.

In the example above, the documentation indicates that a previous skin biopsy was performed at the time the BCC was diagnosed, and the patient has now returned to have the entire lesion removed. As such, it is important to report the malignant lesion excision code 11600.

Question: Do the new skin biopsy codes still have 0-day global period?

Answer: Yes, the new codes still hold a 0-day global period.

Question: If two skin biopsies are performed, one of the lip and the other a tangential biopsy of the cheek, is the skin biopsy reported in addition to the site-specific biopsy?

Answer: Correct, the biopsy of lip (code 40490) is reported in addition to the tangential biopsy (code 11102) with modifier 59 appended to the tangential biopsy code: 40490 and 11102-59.