Documenting Bronchospasm – Learn These ICD-10 and CPT Codes

Documenting Bronchospasm – Learn These ICD-10 and CPT Codes

Bronchospasm occurs when the muscles that line the airways (bronchi) in your lungs tighten and contract. When these muscles tighten, your airways narrow, and cause difficulty in breathing along with frequent coughing and wheezing (a high-pitched whistling sound). Narrowed airways won’t let as much air to come in or go out of your lungs. This in turn may limit the amount of oxygen that enters your blood and the amount of carbon dioxide that leaves your blood. This condition commonly affects people with asthma. However, not everyone with bronchospasm has asthma. Medical billing and coding for bronchospasm is quite challenging. Healthcare practices treating patients suffering from bronchospasm need to know the correct medical codes to report the condition on the medical claims. Outsourcing medical billing and coding is a feasible strategy for accurate and timely claim filing for appropriate reimbursement.

Any swelling, irritation, inflammation, or allergic reaction of the airways can cause bronchospasm. Other factors that can contribute to this disorder include – allergens, chronic obstructive pulmonary disease (COPD), infection of the lungs or airways, exercise, cold weather, smoke inhalation (from a fire or use of tobacco and illicit drugs) and general anesthesia during surgery. Typical symptoms include wheezing, chest pain or tightness, coughing and fatigue.

Diagnosing and Treating Bronchospasm

Under most circumstances, primary diagnosis of this condition will begin with a detailed medical examination. A primary care physician or pulmonologist (who treats lung diseases) will conduct a detailed physical examination wherein they will ask about the patient’s symptoms to check whether he/she has any history of asthma or allergies. They will also check the heartbeats as the patient breathes in and out.

Physicians may recommend lung function tests such as spirometry, lung diffusion capacity, pulse oximetry, lung volume test and Eucapnic voluntary hyperventilation to measure how well the lungs work. If the physician is concerned about other causes of wheezing or shortness of breath, they may also recommend other diagnostic imaging tests like chest X-ray and CT scan to look for problems and other signs of infection in the lungs.

Treatment for this condition generally begins with inhaled medications known as short-acting beta2-agonists. Ventolin or Proventil (albuterol) are common medications that may be used if the patient has difficulty in breathing or shortness of breath. Long-acting bronchodilators like Albuterol help keep airways open for up to 12 hours. Inhaled steroids and oral or intravenous steroids may be prescribed if the bronchospasm is severe. People who suffer from exercise-induced bronchospasm can take short-acting medicines about 15 minutes before they start the workout. Antibiotics will be prescribed for patients who have a bacterial infection.

The diagnosis, screening tests and other procedures performed by pulmonologists or other physicians must be carefully documented using the correct medical codes. Medical billing and coding services ensure this so that claim denials are avoided. Medical codes used for this respiratory disorder include –

ICD-10 codes

  • J98 – Other respiratory disorders
    • J98.0 – Diseases of bronchus, not elsewhere classified
    • J98.01 – Acute bronchospasm
    • J98.09 – Other diseases of bronchus, not elsewhere classified

CPT Codes

  • 94010 – Spirometry, including graphic record, total and timed vital capacity, expiratory flow measurement(s), with or without maximum voluntary ventilation.
  • 94011 – Measurement of spirometry forced expiratory flows in an infant or child through 2 years of age.
  • 94012 – Measurement of spirometry forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age.
  • 94013 – Measurement of lung volumes (i.e., functional residual capacity (FRC); forced vital capacity (FVC), and expiratory reserve volume (ERV) in an infant or child through 2 years of age.
  • 94014 – Patient-initiated spirometry recording per 30 day period of time; includes reinforced education, transmission of spirometry tracing, data capture, analysis of transmitted data, periodic recalibration and review and interpretation by a physician or other qualified health professional.
  • 94015 – Patient-initiated spirometry recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration).
  • 94016 – Patient-initiated spirometry review and interpretation only by a physician or other qualified health professional.
  • 94060 – Bronchodilator responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration.
  • 94070 – Bronchspasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (eg. antigen(s), cold air, methacholine).
  • 94150 – Vital capacity, total (separate procedure).
  • 94200 – Maximum breathing capacity, maximum voluntary ventilation
  • 94250 – Expired gas collection, quantitative, single procedure (separate procedure).
  • 94375 – Respiratory flow volume loop
  • 94617 – Exercise test for bronchospasm, including pre- and post- spirometry, electrocardiographic recording(s), and pulse oximetry
  • 94618 – Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed
  • 94621 – Cardiopulmonary exercise testing, including measurements of minute ventilation, CO2 production, CO2 uptake, and electrocardiographic recordings
  • 94726 – Plethysmography for determination of lung volumes and when performed, airway resistance.
  • 94727 – Gas dilution or washout for determination of lung volumes, and when performed distribution of ventilation and closing volume.
  • 94728 – Airway resistance by impulse oscillometry
  • 94729 – Diffusing capacity (eg. Carbon monoxide, membrane)
  • 94750 – Pulmonary compliance study (eg. Plethysmography, volume and pressure measurements).
  • 94760 – Noninvasive or pulse oximetry for oxygen saturation, single determination.
  • 94761 – [Oximetry] multiple determinations (eg. During exercise).
  • 94762 – [Oximetry] by continuous overnight monitoring (separate procedure).
  • 94799 – Unlisted pulmonary service or procedure.
  • 95012 – Nitric oxide expired gas determination.
  • 95070 – Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine or similar compounds.

It is important to seek emergency help if the patient experiences shortness of breath or breathing difficulty. Following the first incidence, it is essential to develop a definite plan of care that may help reduce the patient’s risks of suffering subsequent episodes of bronchospasm. These include – warming up for at least 5 to 10 minutes before exercise, consuming lots of water throughout the day (to loosen up any mucus in your chest), quitting the habit of smoking or staying away from smoke and reducing the chances of allergies.

Medical billing and coding for bronchospasm can be complex, as there are several codes associated with the condition. By outsourcing these tasks to a reliable and established anesthesiology medical coding company or other medical coding service provider (that offers the services of AAPC-certified coding specialists), healthcare practices can ensure correct and timely medical billing and claims submission.

Documenting Preventive Medicine Services with CPT and ICD-10 Codes

Documenting Preventive Medicine Services with CPT and ICD-10 Codes

A unique medical specialty recognized by the American Board of Medical Specialties (ABMS), preventive medicine services or well visits aim at protecting, promoting, and maintaining health and well-being and preventing disease, disability, and death for individuals, communities, and defined populations. Medicare explains that the goals of these wellness visits are health promotion and disease prevention and detection. Preventive medicine has three specialty areas – aerospace medicine, occupational medicine, and public health and general preventive medicine. Medical coding services to document preventive visits involve using the correct CPT and ICD-10 codes to report the services provided.

Services provided will also vary by patient circumstance. While the services for a young child will assess physical growth and developmental milestones such as speech, crawling, and sleeping habits, an adolescent preventive service may include scoliosis screening, assessment of growth and development, and a review of immunizations. A comprehensive preventive visit for an adult female patient will include a gynecologic examination, pap smear, and breast exam and for an adult male’s exam, services would include an examination of the scrotum, testes, penis, and the prostate for older patients.

The preventive comprehensive exam is different from a problem-oriented comprehensive exam, as its components are based on age and risk factors rather than a presenting problem. Unlike other evaluation and management (E/M) services, preventive services do not have specific documentation guidelines required to support the service provided.

CPT codes

CPT defines a preventive medicine service as an age – and gender-appropriate comprehensive history and physical exam that includes anticipatory guidance and risk factor reduction. A dedicated set of CPT codes to describe preventive medicine services range from 99381 to 99397. These codes can report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults.
Code assignment is determined by the patient’s age (as detailed in the code descriptor), and whether the patient is new (99381-99387) or established (99391-99397).

New Patient

  • 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
  • 99382 ———; early childhood (age 1 through 4 years)
  • 99383 ———; late childhood (age 5 through 11 years)
  • 99384 ———; adolescent (age 12 through 17 years)
  • 99385 ———; 18-39 years
  • 99386 ———; 40-64 years
  • 99387 ———; 65 years and older

Established Patient

  • 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
  • 99392 ———; early childhood (age 1 through 4 years)
  • 99393 ———; late childhood (age 5 through 11 years)
  • 99394 ———; adolescent (age 12 through 17 years)
  • 99395 ———; 18-39 years
  • 99396 ———; 40-64 years
  • 99397 ———; 65 years and older

It is recommended to report the appropriate Office/Outpatient code from 99201-99215, if an abnormality is encountered in the process of performing this preventive medicine evaluation and management service, and if additional work is significant to perform the key components of a problem-oriented E/M service. Modifier 25 should also be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service.

ICD-10 Codes

Every billed service must be supported by an ICD-10-CM code(s) that describe the reason for that service.

  • Z00.110 Health examination for newborn under 8 days old
  • Z00.111 Health examination for newborn 8 to 28 days old
  • Z00.121 Encounter for routine child health examination with abnormal findings
  • Z00.129 Encounter for routine child health examination without abnormal findings
  • Z00.00 Encounter for general adult medical examination without abnormal findings
  • Z00.01 Encounter for general adult medical examination with abnormal findings
  • Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Even though the Affordable Care Act (ACA) requires insurers to cover recommended preventive services without any patient cost-sharing, exact coverage and reporting requirements may vary from payer to payer. Experienced medical billing and coding companies provide the services of skilled medical coders who are up to date with the coding changes and updates related to E/M and preventive medicine services.

A Look at the CPT Codes to Report Renal Dialysis

A Look at the CPT Codes to Report Renal Dialysis

More than 660,000 Americans are being treated for kidney failure or end stage renal disease (ESRD) and of these, 468,000 are dialysis patients, according to the latest U.S. Renal Data System Annual Data Report. Demand for kidney dialysis is expected to increase with the growth in the elderly population and the increasing prevalence of chronic conditions such as diabetes, hypertension and heart disease. However, with the increasing body of regulations, reporting nephrology diagnoses and treatment has become complex. Medical coding outsourcing helps providers ensure accurate reporting of services rendered for appropriate reimbursement.

Renal Dialysis

Kidney transplantation is the best treatment for ESRD and dialysis is the only alternative to transplantation. The function of the kidneys is to filter the blood, turning harmful waste products and excess fluid into urine and removing them from the body. Dialysis is needed to clean the blood when the kidneys stop functioning properly. There are two main types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis involves pumping a patient’s blood through a machine for filtration and passing it back into the body. The procedure is carried out at a medical facility 3 days a week, with a session lasting between 3-5 hours.

Peritoneal dialysis uses the patient’s own abdomen as the filter. A catheter is inserted through an incision into the peritoneal cavity. Fluid is pumped into the peritoneal cavity via the catheter and waste is exchanged from the blood and flushed out on a regular basis. While it does not involve regular visits to a medical facility, peritoneal dialysis requires regular treatment at home.

The CPT codes to report dialysis are as follows:

CPT 90935-90940 Hemodialysis Procedures

  • 90935 – Hemodialysis procedure with single provider evaluation – This code is used to report a single treatment that includes physician evaluation
  • 90937 – Hemodialysis procedure requiring repeated evaluations, with or without substantial revision of dialysis prescription – This code is used to report services provided by the physician during the patient’s hemodialysis treatment
  • 90940 Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method

CPT 90945-90947 Miscellaneous Dialysis Services and 90989-90999 Other Dialysis Procedures

These code ranges cover services not found in other code ranges for dialysis procedures such as peritoneal dialysis, hemofiltration, and other continuous renal replacement therapies.
90945-90947 Miscellaneous Dialysis Services

  • 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) with single physician evaluation
  • 90947 Dialysis procedure other than hemodialysis (e. g. peritoneal, hemofiltration) requiring repeated evaluations with or without substantial revision of dialysis prescription

90989-90999 Other Dialysis Procedures
This code range includes procedure codes to report dialysis training and hemoperfusion. Hemoperfusion is a method to remove toxins from the blood that involves perfusing the blood through activated charcoal or resin and then transfusing the blood back to the patient.

  • 90989 Dialysis training, complete(the date of service should be the date that training was completed and the days/units should be ‘1’)
  • 90993 Dialysis training, uncompleted courses or subsequent training (enter the exact dates of service for each training session; the days or units should be the number of training dates)
  • 90999 Unlisted dialysis procedure, inpatient or outpatient

Bundled CPT Codes for Dialysis Circuit Interventions

In 2017, three new codes (36901, 36902, 36903) were introduced to bundle all work involved in the percutaneous management of a patient dialysis access and three codes (36904, 36905, 36906) were introduced to bundle endovascular dialysis access thrombectomy procedures.

90951-90970 End-stage Renal Disease Services

The codes to report end-stage renal disease services are in the range 90951-90970. For patients with ESRD, dialysis services are reported on a monthly basis, with a code from the 90951-90966. Codes 90967-90970 are billed per day for services lasting less than a full month. The codes are distinguished by age-specific services and location where the services are provided such as outpatient, home, or inpatient setting.

Medicare Coverage for Dialysis

Medicare covers

  • Hospital inpatient dialysis
  • Outpatient dialysis from a Medicare-certified hospital or free-standing dialysis facility
  • Home dialysis training, sometimes called self-dialysis, from a dialysis facility. If a Medicare patient needs dialysis, a clinic that is certified to provide home training and support can bill Medicare for a certain number of training sessions, depending on the modality. CMS pays up to 15 training sessions for peritoneal dialysis and 25 sessions for hemodialysis. This includes:
    • Training for the patient and caregivers who will provide home dialysis
    • Home dialysis equipment and supplies
    • Medications related to treatment (medication is only covered when overseen by a doctor)

Nephrologists need to ensure coding accuracy and appropriate documentation to receive optimal reimbursement for their services. Partnering with an experienced nephrology medical billing and coding company can help providers ensure accurate reporting of dialysis and other procedures while meeting the additional claim submission requirements of Medicare and private payers.

Coding Vaginal Hysterectomy – Be Familiar with the CPT Codes

Coding Vaginal Hysterectomy – Be Familiar with the CPT Codes

Hysterectomy is the second most frequently performed surgical procedures in the United States with reports suggesting about 650,000 procedures being performed each year. The surgical procedure is done to remove a woman’s uterus or womb. After this procedure, a woman may no longer have menstrual periods and can’t become pregnant. In some cases, the surgery also removes the ovaries and fallopian tubes. If you have both ovaries taken out, you will enter menopause. Surgeons can perform hysterectomy vaginally, abdominally or laparoscopically, with each option depending on the person’s specific condition. Vaginal hysterectomy is a surgical procedure to remove the uterus through the vagina. When compared to other types, hysterectomy through the vagina is minimally invasive, so recovery is normally shorter and easier. Vaginal hysterectomy is a common procedure in gynecology practice, and medical coding for the same is a real challenge due to many code choices. Along with the specific surgical approach and the extent (whether it’s total or partial) of the hysterectomy, accounting for related performed procedures is vital to code selection. OB-GYN (obstetrician-gynecologist) or other general surgeons performing vaginal hysterectomy should correctly document the procedures performed in the patients’ medical records. Outsourcing medical billing and coding tasks to a reliable medical billing and coding company can help physicians simplify their documentation process.

Vaginal Hysterectomy

As part of vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it. The uterus is finally removed through the vagina. Depending on the patient’s condition, the procedure can last anywhere between 60 – 90 minutes.

Why Is Vaginal Hysterectomy Done?

The American College of Obstetricians and Gynecologists (ACOG) recommends vaginal hysterectomy for benign disorders where possible. Surgeons generally conduct this procedure to treat different types of gynecologic problems, including –

  • Small uterine fibroids or benign growth in the uterus wall
  • Endometriosis – when the tissue lining your uterus (endometrium) grows outside of the uterus
  • Uterine prolapse when the uterus has slipped out of place
  • Heavy or irregular menstrual bleeding that does not respond to other treatments
  • Gynecologic cancer (involving cancer of the uterus, cervix, endometrium or ovaries)
  • Chronic pelvic pain

Although any surgery has its own set of risk elements, some risk factors that accompany vaginal hysterectomy are – heavy bleeding, infection, blood clots in the legs or lungs, infections and injury to other pelvic and abdominal organs. Surgical risks are quite higher in women who are obese or who have high blood pressure.

The Procedure

For those who are undergoing vaginal hysterectomy, regional anesthesia will be preferred as it will block the sensation in the lower half of your body.

Patients need to lie in a position similar to that for a Pap test. As part of the procedure, the surgeon will make an incision inside your vagina to get to the uterus. Using long instruments, your surgeon clamps the uterine blood vessels and separates the uterus from the connective tissue, ovaries and fallopian tubes. Uterus is removed through the vaginal opening, and absorbable stitches are used to control any bleeding inside the pelvis.

Applicable CPT Codes

Obstetrics and Gynecology medical billing and coding is challenging, as it involves numerous rules related to reporting the procedure accurately. Obstetrician-gynecologists or other surgeons performing vaginal hysterectomy must use the relevant CPT codes to bill for the procedure. The CPT codes for vaginal hysterectomy include –

  • 58260 – Vaginal hysterectomy, for uterus 250 g or less
  • 58262 – Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
  • 58263 – Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
  • 58267 – Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
  • 58270 – Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
  • 58275 – Vaginal hysterectomy, with total or partial vaginectomy
  • 58280 – Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele
  • 58285 – Vaginal hysterectomy, radical (Schauta type operation)
  • 58290 – Vaginal hysterectomy, for uterus greater than 250 g
  • 58291 – Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
  • 58292 – Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
  • 58293 – Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
  • 58294 – Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Recovery after the Procedure

As soon as the hysterectomy procedure is complete, patients will be shifted to a recovery room and their heart rate, blood pressure, level of pain and feelings of nausea will be closely monitored. Medications to reduce pain and prevent infections will be directly administered. The average period of hospital stay after the procedure is generally two days or possibly longer.

In the first few weeks after a vaginal hysterectomy, it is normal to have bleeding (similar to a light menstrual period) that comes and goes but decreases over time. Patients may also experience mild pain, discomfort in the lower belly and bloating or constipation as the bowel has temporarily slowed down.

Although the procedure is less invasive than other types, it will still take a considerable amount of time for patients to fully recover and get back to their normal activities. The time of recovery will differ from one individual to another and may depend on the type of procedure performed. In most cases, a full recovery may take up to 2-3 weeks. Therefore, patients need to limit their activities for a few weeks and follow the post-operative instructions carefully. There are several things to avoid for a smooth recovery –

  • Avoid putting anything in the vagina for at least 4 to 6 weeks
  • Avoid strenuous tasks and heavy lifting during the first 6 weeks
  • Avoid vaginal intercourse until six weeks after surgery
  • Avoid swimming until the vaginal stitches have healed completely

Following the above instructions carefully can lead to quick healing and reduced risk of complications. Taking adequate amount of rest, consuming a high-fiber diet and attending regular follow-up visits is important for a healthy surgical recovery.

Medical billing and coding requires a high level of knowledge regarding appropriate coding modifiers and payer-specific medical billing are essential for correct and on-time reimbursement. With all the complexities involved, the support of a reliable and experienced medical coding service provider can be useful for reporting vaginal hysterectomy procedure correctly.

Medical Coding for Skin Biopsies – Use the Correct CPT Codes

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
  • Warts

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.