Continuing our series on some notable changes to CPT this year, codes for biopsies of skin lesions have been expanded.
Prior to this year, we had two codes to represent a biopsy of a skin lesion: CPT 11100 for the first lesion biopsied and CPT 11101 for each additional lesion biopsied. When these codes were created many years ago, they were sufficient to accurately report the types of biopsies being performed at the time. As time has gone on, though, many different techniques for biopsying a lesion have emerged, and the work that goes into performing a biopsy can vary based on the technique used. For that reason, the AMA revised the skin lesion biopsy codes this year to more accurately describe the “method” for obtaining the biopsy.
Below are the new codes and their definitions. Notice that we have a primary or parent code for the first lesion biopsied for each method of biopsy and an add on code for each additional/separate lesion:
- CPT 11102: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); single lesion
- + CPT 11103: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (list separately in addition to code for primary procedure)
- CPT 11104: Punch biopsy of skin (includes simple closure when performed); single lesion
- +CPT 11105: Punch biopsy of skin (includes simple closure when performed); each separate/additional lesion (list separately in addition to code for primary procedure)
- CPT 11106: Incisional biopsy of skin
(e.g., wedge) (including simple closure, when performed); single lesion
- +CPT 11107: Incisional biopsy of skin
(e.g., wedge) (including simple closure, when performed); each separate/additional lesion (list separately in addition to code for primary procedure)
To understand how to code with the expanded options available for this procedure, it is necessary to first understand some key definitions and rules for their use.
Key Definitions:
- The skin is made up of two layers of tissue. The epidermis is the outermost layer of the skin and provides protection against germs and a water-proof barrier to protect our inside organs. The dermis is the inner layer of the skin which lies between the epidermis and the subcutaneous tissue and provides toughness and flexibility for the skin.
- These different methods of biopsies may take a “partial thickness” sample of the skin (meaning only part of the layers of the skin in the area of the biopsy are removed, such as the epidermis layer only). Alternatively, they may take a “full thickness” sample of the skin (meaning the surgeon cuts through the epidermis and full thickness of the dermis down to the subcutaneous tissue to take a sample that includes all layers of the skin tissues).
- Tangential refers to a slicing motion with a blade. In this type of biopsy, the physician takes a “slice” of the skin and is taking a “partial thickness” sample of the skin lesion, usually taking only the epidermis. The physician may take part of the underlying dermal layer if needed, but in either case, is not cutting full thickness through the skin and taking epidermis and the full thickness of the dermal layer. Some synonyms for tangential include “curetting,” “scooping,” or “shaving” to obtain a biopsy, and you may see these terms used in procedure reports.
- A punch biopsy involves taking a “full thickness” column of tissue from a lesion using a punch tool. Punch tools come in different sizes so you may see a punch tool mentioned along with a size in millimeters (e.g., 12.0 millimeter punch tool was then used to obtain a biopsy)
- An incisional biopsy as the name suggests involves creating an incision with a blade. The incision may either be vertical or may involve cutting out a “wedge” of tissue. This type of biopsy is “full thickness” where tissue through the full thickness of the epidermis and dermis is excised and even the underlying subcutaneous fat may be removed if needed.
Key Guidelines:Now that we understand some key terms used in these code descriptions, we also need to be aware of rules about how the codes should be used.
- These codes can be used for biopsies anywhere in the body as long as the biopsy is of a “skin lesion.” The codes are not restricted to use for a specific anatomic site(s). For biopsy from tissues other than the skin, there are codes throughout the surgery section of CPT to represent those biopsies. For example, if a surgeon documented a biopsy of the anterior two-thirds of the tongue, you would report CPT 41100 rather than one of these skin biopsy codes.
- When coding more than one biopsy during the same case, you can only code one primary/parent code for the most extensive biopsy performed. You would then report all additional biopsies with add on codes. Example: A physician performs an incisional wedge biopsy of a lesion on the right forearm. He then performs a punch biopsy of a second lesion on the upper arm near the shoulder. In this example, you would code CPT 11106 for the most extensive biopsy technique (the incisional biopsy) and code add on code 11105 for the punch biopsy of the second lesion. How did I decide which primary biopsy and add on biopsy code to use? You can determine this both through checking your NCCI edits and your CPT guidelines. If I check NCCI edits between 11106 (first lesion incisional biopsy) and 11104 (first lesion punch biopsy), I see that CPT 11106 has higher total RVUs and is the column 1 (or more comprehensive) code in the NCCI edit. This confirms that the primary code CPT 11106 should be coded and that the punch biopsy should be reported with the add on code using NCCI edits. Your CPT parenthetical notes under these codes can also be useful guides to determining which primary codes the add on may be reported with. For example, underneath CPT 11105 (add on code for each additional lesion biopsied with a punch technique), it tells us to code first 11104 (a first lesion punch biopsy) or 11106 (a first lesion incisional biopsy). Underneath CPT 11107 though (add on code for each additional lesion biopsied with an incisional technique), it tells us to code first CPT 11106 (a first lesion incisional biopsy). So in our example here, we could not have reported CPT 11104 (first lesion punch biopsy) and CPT 11107 (add on code for each additional lesion biopsied with an incisional technique) without violating the CPT guidelines.
- The tangential biopsy codes which again involve a “slicing” of “shaving” motion can appear similar to other CPT codes like shave removals of lesions. To decide whether to code a tangential biopsy code or a shave removal code, look at the intent of the procedure. If the intent is to obtain tissue for a diagnosis/pathology, code the procedure as a tangential biopsy. If the intent is to completely remove the lesion, code the procedure as a shave removal.
- The biopsy codes include “simple closure” when performed. That means that it is not necessary for the surgeon to close the wound after the biopsy in order to use these codes, but that if he does so, and the closure is “simple” you do not get to report a separate code for that closure. The CPT guidelines define simple repair as “one layer closure” (meaning one layer of stitches is placed or techniques such as tissue glue that do not involve the use of stitches are used). In the rare event that a biopsy results in the need for a more extensive intermediate repair (i.e., layered closure where at least one layer is in the subcutaneous tissues or deeper) or complex repair (i.e., more than layered closure involving techniques such as debridement, stents, retention sutures, extensive undermining, or scar revision), you may report a separate CPT code for the repair.
Let’s look at an example together to put these definitions and guidelines into practice:
Example #1: A 30 year old male presents with a raised skin lesion on the right thigh that has grown and changed in color over the past few weeks. He is brought to the procedure room today for tissue diagnosis.
After prep and drape, local anesthetic was applied around the right thigh lesion. A scalpel was used to shave a 0.5 cm strip of epidermal tissue.from the lesion. Bleeding was controlled and patient tolerated the procedure well. He will follow up with me in 1 week for pathology results.
Answer example #1: The bold portions of the procedure note help us with our code selection. First of all we see in the history provided that the intent of the procedure is “tissue diagnosis” confirming this is a biopsy. We also see the indication is a “skin lesion” of the thigh confirming that we should select a code from the skin lesion biopsy codes in the integumentary section of CPT rather than from another section of the CPT manual.
From there, we see the surgeon using a scalpel (a type of blade) to “shave” epidermal tissue only. So the technique for biopsy is a “shave method” and this is a “partial thickness” sample since only the epidermal tissue is taken. These details confirm the biopsy type is tangential. Finally, we see again the physician stating the patient will follow up for biopsy results in 1 week, again confirming intent here is to obtain a biopsy.
Since we have only one skin lesion and that lesion is biopsied using a tangential technique, we will report CPT 11102.
