Internal Medicine Coding: Skin Biopsy Timing, Location, Intent

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Are you aware when to report skin biopsy separately with or in place of other procedures such as shaving or excision? If not, read on and find out:


Normally, you may report skin biopsy separately when the biopsy occurs at a separate location from an excision or other removal or when the results of the biopsy prompt the more extensive removal by excision or other method.


For example, if your internist excises a lesion on the right hand of the patient and biopsies a different lesion (either on the right hand or elsewhere on the body), the excision and biopsy are separate. Add modifier 59 (Distinct procedural service) to the biopsy code to indicate that it occurred at a different location from the excision.


Remember: Biopsy is a standard practice when removing skin lesions. In most instances, you'd not report biopsy of the same lesion separately with an excision or other removal. In an alternative situation, the internist takes a biopsy by shave technique and submits the sample to pathology for examination. The results show a malignant lesion, which your internist ...
... then removes in its entirety, with margins, by excision. In this instance, the biopsy and excision are again separate as the biopsy led to the decision for the excision.


While coding, add modifier 58 (staged or related procedure or service by the same doctor during the postoperative period) to the excision code to show that this was a staged procedure following the biopsy. Since 11100 has 0 global days, the only time this is an issue is when a frozen section is done and the biopsy and treatment are carried out on the same day.


Key: Your doctor's intent has a lot to do with distinguishing between a biopsy and removal by shaving, excision, or some other method. The AMA has stressed this point, saying that the intent of a biopsy is to remove a portion of skin, suspect lesion or entire lesion so that it can be examined pathologically. In comparison, the intent of other integumentary procedures that involve removal of tissue is different. Normally, they are carried out for the intent of removing the entire lesion.


Since physicians often use the terms "biopsy" and "excision" interchangeably, you may find questioning your physician on those claims useful when the terminology and intent are not clear.


For more on this and for other specialty-specific articles to assist your internal medicine coding, sign up for a good medical coding resource like Coding Institute.