Coding Lesion Biopsies

This edition of “Spotlight on CPT” will present information regarding the coding for the biopsy of lesions. In CPT, it is important to remember that just because a specimen goes to Pathology, that does not necessarily mean a biopsy was performed. It is routine for lesions that are totally removed to be sent for pathology testing.

However, when a lesion is simply biopsied, there are three different methodologies by which these can be done: incisional, punch, and tangential. There is also a hierarchy associated with removals when more than one lesion is biopsied and different methodologies are employed. 

At the top of the hierarchy are incisional biopsies. Sharp blades are used for these biopsies in order to remove a full-thickness tissue sample. Full-thickness means the incision is down through the dermis and into subcutaneous tissue. These codes are reported with codes 11106 for a single lesion and an add-on code of 11107 for each additional or separate lesion biopsied in the same way.

The second type of biopsy and next in the hierarchy is a punch biopsy. When these biopsies are performed, a cylindrical full-thickness sample is obtained. These biopsies are reported with codes 11104 for a single punch biopsy of the skin. Add-on code 11105 would be assigned for each additional or separate punch biopsy that is done.

The final type of biopsy and lowest in the hierarchy is the tangential biopsy. This is done with a shave, scoop, or saucerization technique. This means that only tissue in the epidermis is removed (with possibly the upper part of the dermis) and the lesion may extend deeper into dermal tissue. Tangential biopsy codes are 11102 for a single lesion and add-on code 11103 for each additional or separate biopsy performed in that manner.

Tangential biopsies may easily be confused with shave removals of lesions. It is the provider’s responsibility to indicate the intent of the procedure as either biopsy or removal. Coding professionals may look for evidence of suspicious lesion or change in shape/color to help identify the intent as a biopsy. Therapeutic removal may be suggested when the lesion is being rubbed by waistband or bra strap or is being nicked while shaving. 

When a single lesion is biopsied, code choice is easy. Assign the code based on the method of removal.  However, when more than one lesion is removed, that requires understanding of the hierarchy. For example, a patient has a punch biopsy of the right upper arm, and two incisional biopsies of the left lower leg. This would be coded with:

11106 for the first incisional biopsy

11107 for the second incisional biopsy

11105 for the punch biopsy (add-on code- not the code for a single lesion as punch biopsies are second in the hierarchy behind incisional biopsies).

Now, light has been shed on coding lesion biopsies.
 

 

About the Author

Dianna Foley, RHIA, CHPS, CCS, CDIP, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as Eastern Gateway Community College’s program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.