Biopsies are used to obtain a sample of your tissue or cells for diagnostic histopathologic examination performed independently or unrelated/distinct from other procedures/services. The removal of tissue or cells for analysis is called a biopsy. A skin biopsy is a procedure in which a physician cuts and removes small samples of skin or cells from the surface of your body to get it tested. The sample obtained from a skin biopsy is further examined to diagnose certain skin conditions such as skin tumors, infections and other types of growth or skin conditions. A biopsy of a lesion of the skin can help physicians report the difference between a skin cancer and a benign or noncancerous lesion. The skin sample obtained during a biopsy is further sent for laboratory analysis under a microscope. Dermatology medical coding involves several difficult aspects for coders to memorize unique terms related to sizing wounds and lesions. As skin procedure codes take into account the type of removal, the size and location of the lesion (such as length, depth, width, and circumference), the provider’s intent and pathologic results, documenting the service and selecting the right medical codes can be confusing. Outsourcing the task to a reliable and experienced medical billing and coding company is a feasible strategy that helps physicians simplify their documentation process. Coders must be familiar with terminology related to benign and malignant masses along with actions such as shaving, destruction, and performing biopsies.
Why Is a Skin Lesion Biopsy Done?
Generally, a skin biopsy is performed to determine the cause of a growth, sore or rash and could include –
- Skin cancer including basal cell carcinoma, squamous cell carcinoma and melanoma
- Rashes or blistering skin conditions
- Pre-cancerous cells
- Non-cancerous growths
- Chronic bacterial or fungal skin infection
- Changing moles
- Actinic keratosis
The potential risk factors associated with this procedure include – excessive bleeding from the biopsy site, pain, skin infections, local reaction to the anesthetic, scarring and other healing problems.
Types of Skin Biopsies
There are four main types of skin biopsies which include –
- Shave biopsy – Physicians will remove only a small section of the top layers of skin (epidermis and a portion of the dermis) using a special razor blade or scalpel.
- Punch biopsy – Physicians use a circular tool to remove a small section of skin including deeper layers (epidermis, dermis and superficial fat).
- Excisional biopsy – This type is used to remove the entire lesion/abnormal skin, including a portion of normal skin down to or through the fatty layer of skin.
- Incisional biopsy – This is used to remove a small part of a larger lesion.
After the biopsy, the wound will be covered with gauze and other bandaging. Patients will be able to go home once the sample has been taken.
Undergoing Skin Biopsy – Preparations Required
Generally performed in the doctor’s office, patients undergoing skin biopsy will be asked to change into a hospital gown so that the area of suspect skin can be more easily seen and removed. Before undergoing the procedure, patients must disclose information about – current medicines consumed (including over-the-counter drugs, street drugs, or herbal or nutritional supplements), any allergies/reactions to medications (especially to local anesthetics, such as lidocaine or novocaine, or to iodine cleaning solutions, such as Betadine), pregnancy and bleeding problems if any.
The physician will first cleanse the biopsy site (with a sterile soap solution) and then numb the skin by using a local anesthetic (pain-relieving) injection, usually lidocaine. Patients will experience a brief prick and stinging sensation as and when the medicine is injected. After the skin is numb, the physician will perform the biopsy and the tissue will be removed. The removed portion of tissue will be sent to the laboratory for analysis by a pathologist. After the procedure, the wound will be covered with gauze and other bandaging. A skin biopsy typically takes about 15-20 minutes, including the preparation time, dressing the wound and instructions for at-home care.
CPT Codes for Skin Biopsies
Dermatology medical coding involves the use of specific CPT codes to document different types of skin biopsies. The CPT codes for skin biopsies include –
For the first biopsy, submit code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion). For each separate biopsy after the first one, use the add-on code 11101 – Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed separate procedure; each separate/additional lesion [List separately in addition to the code for primary procedure].
For instance, if three lesions are biopsied, codes 11100, 11101 and 11101 should be submitted. If skin biopsy is performed more than the maximum number of times, it is important to submit supporting documentation to avoid denials. If the removal is simply for diagnosis, the procedure is coded as a biopsy. If the entire lesion is removed, the excision codes should be used.
The new CPT codes that range from 11102 – 11107 are reported on the basis of method of removal, which offers greater specificity. The new CPT codes are as follows –
- 11102 – Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette) single lesion
- +11103 – Each separate/additional lesion (List separately in addition to code for primary procedure)
- 11104 – Punch biopsy of skin (including simple closure, when performed) single lesion
- +11105 – Each separate/additional lesion (List separately in addition to code for primary procedure
- 11106 – Incisional biopsy of skin (including simple closure, when performed) single lesion
- +11107 – Each separate/additional lesion (List separately in addition to code for primary procedure
Prior to the above new CPT codes, biopsies were reported with CPT code 11100 for the first lesion and 11101 for each additional lesion biopsied regardless of method of removal. However, the new biopsy codes are reported based on method of removal including –
- Tangential biopsy (Codes – 11102 and 11103)
Tangential biopsy includes removal via shave, scoop, saucerization or curette. The procedure is performed with a sharp blade like a flexible biopsy blade, obliquely oriented scalpel or curette. A sample of epidermal tissues is removed with or without portions of the underlying dermis. This type of biopsy does not involve the full thickness of the dermis. When the full thickness of the dermis is involved, the procedure is reported using the codes – 11300-11313 (removal of epidermal or dermal lesions).
- Punch biopsy (Codes -11104 and 11105)
Performed using a punch tool, the purpose of this biopsy is to remove a sample of a cutaneous lesion for a diagnostic pathologic examination. Simple closure is included and cannot be billed separately.
- Incisional biopsy (Codes – 11106 and 11107)
An incisional biopsy requires a sharp blade (not a punch tool) to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating deep into the dermis, into the subcutaneous space. An incisional biopsy may sample subcutaneous fat. When the entire lesion is excised, it is important report the excision codes – 11400-11646 (depending on type of lesion – benign or malignant).
- Multiple Biopsies
If more than one biopsy is performed on the same date, report only one primary biopsy code. When more than one biopsy is performed using the same technique, the appropriate primary biopsy code is reported for the first biopsy and the add-on code is reported for each additional lesion.
Recovery after the Procedure
Once the skin biopsy is complete, patients may experience some soreness around the biopsied site for a few days. Physicians will either put a bandage or stitches (in some cases) over the biopsy site. In most cases, physicians may instruct patients to keep the bandage over the biopsy site until the next day. They may be advised to change the bandage daily, wash the wound and apply antibacterial ointment. Tylenol is usually sufficient to relieve discomfort. However, patients who have stitches around the biopsy site need to keep the area as clean and dry as possible. Healing of the wound can take several weeks, but is usually complete within two months. Wounds on the legs and feet tend to heal slower than those on other areas of the body.
Medical billing and coding can be complex and requires knowledge regarding appropriate coding, modifiers and payer-specific medical billing for correct and on-time reimbursement. With all the complexities, the support of an experienced medical coding service provider could be useful to report skin biopsy procedures correctly for optimal reimbursement. Professional coders in reliable medical billing and coding companies can ensure accurate reporting of diagnostic and procedure details.