Coding for Biopsies, Shave Removals, and Excisions

In dermatology, samples of skin and subcutaneous tissue are routinely removed to establish a diagnosis, treat symptomatic lesions, or remove potential tumors. The Current Procedural Terminology (CPT) codes used in billing for these procedures typically are generic, but it is important to differentiate between 3 degrees of tissue removal—biopsy, shave removal, and excision—when billing for these services since different codes may be appropriate in each of these circumstances.

Biopsy

Specifically, biopsy (CPT codes 11100/11101) is described as an “independent…procedure to obtain tissue for pathologic examination.”¹ The method of biopsy is not specified by CPT and can include any of the following, as long as the primary purpose of the procedure is to remove tissue for analysis: removal by scissors, shaving with a blade or specialized instrument to any level including the subcutaneous fat, extraction using a punch, and excision down to the subcutaneous fat with a scalpel. The feature that differentiates biopsy from shave removal or excision is not depth or extent of tissue mobilization but the intent “to remove a portion of skin, suspect lesion, or entire lesion so that it can be examined histologically.”² The underlying assumption is that neither definitive clinical nor histologic diagnosis exists prior to biopsy, the purpose of which is to help establish the identity of the lesion.

If the tissue within a large, single lesion is sampled at several separate locations at the same visit, then only a single unit of a single biopsy code (eg, either 11100, 11101, or some site-specific code) should be reported.In contrast, if a number of discrete lesions in the same approximate anatomic area were sampled for diagnoses, each sample taken from separate lesions would constitute a distinct biopsy and would be billed as a separate unit of service.

Shave Removals and Excisions

Shave removal of skin lesions (CPT codes 11300–11313) includes the removal of tangential or saucerized skin lesions to a level no deeper than the base of the dermis. The CPT provides no detailed guidance regarding differentiation of codes for shave removal versus biopsy when a specimen is submitted for histopathologic examination other than the definition of biopsy that was discussed previously. If the tissue is removed specifically for establishing diagnosis, then by definition the procedure should be coded as a biopsy. On the other hand, shave removal implies the intent to completely remove a lesion that already has a presumptive clinical or histologic diagnosis or is being removed for some purpose other than diagnosis (eg, symptomatic relief).

Shave removals are, however, clearly different than excisions (CPT codes 11400–11646), which must proceed through the entire dermis to the subcutis. Additionally, skin lesion excisions include margins, as the intent of an excision procedure is to remove the entire lesion along with a margin of normal skin around it.²

Specialized Biopsy and Excision Codes

While most biopsies, shave removals, and excisions are performed using generic codes, there are specialized circumstances when more specific codes may be preferable. For instance, there are site-specific skin biopsy codes for the nail unit (11755), vermilion and mucosal lip (40490), penis (54100), vulva (56605), and external ear (69100) that take into account the additional complexity of biopsy at these anatomic locations. There also is a site-specific code for eyelid biopsy (67810), which was redefined in 2013 as an “incisional biopsy of eyelid skin including lid margin.”¹ Therefore, biopsies of eyelid skin that do not remove the eyelid margin must be coded as 11100/11101, or if the entire cutaneous lesion was removed, can be reclassified as shave removals, which would be coded in the 11310 to 11313 range.

Specialized excision codes include those of the soft tissue. Soft tissue excision codes typically used by dermatologists are not numbered consecutively, are site-specific, and are typically used for resection of benign tumors confined to the subcutaneous tissue below the skin but above the deep fascia. Cysts of all types, including epidermoid and pilar cysts, are specifically excluded from this code set regardless of how large or complex they may be, as they protrude into the dermis or above and are not exclusively in the subcutis. However, lipomas meet the definition for soft-tissue excision, and therefore site-specific soft tissue excision codes can be used in lieu of traditional skin excision codes. The soft-tissue excision codes are distributed throughout the CPT manual, with distinct codes for the abdominal wall (22902, 22903); leg or ankle (27618, 27632); back or flank (21930, 21931); external auditory canal (69145); upper arm or elbow (24075, 24071); face or scalp (21011, 21012); hand or finger (26115, 26111); foot or toe (28043, 28039); forearm or wrist (25075, 25071); hip or pelvis (27047, 27043); thigh or knee (27327, 27337); neck or anterior thorax (21555, 21552); and shoulder (23075, 23071). In general, there are 2 codes for each area—one for smaller and one for larger excisions—but they frequently are out of order (ie, the code associated with a higher numerical value may correspond with the smaller excision). Care should be taken in selecting the correct code. The specific size cutoffs for the various soft tissue excision code sets are different, so it is important to be familiar with the particular CPT descriptions for each.