CPT Coding for Biopsies, Shave Removal and Excision: The Differences are in the Details
The words biopsy, shave removal or excision may seem like synonyms for the basic procedures; each accomplishes the goal of diagnosing disease, relieving symptoms, and/or treatment. A recent article published in Cutis notes that for CPT coding purposes, however, they are three separate procedures and therefore should be coded differently. Distinguishing exactly how to code each procedure comes down to the details.
A biopsy is the most general category of the three. Biopsy is simply described as an “independent procedure to obtain tissue for pathologic examination.” Since the method of biopsy is not defined in the coding it can include: 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 key distinguishing requirement is that the primary purpose of the procedure is to remove tissue for analysis.
This intent differentiates the procedure from shave removal or excision. Shave excision coding is subtly different from biopsy. If the removal is simply for diagnosis, than it gets coded as a biopsy. If, however, the shave removal is used to completely remove a lesion that already has a presumptive clinical or histologic diagnosis or is being removed for some purpose other than diagnosis (e.g., symptomatic relief), then it gets coded with a different CPT code.
Excisions have a more absolute definition: they must proceed through the entire dermis to the subcutis and include margins, as the intent of an excision procedure is to remove the entire lesion along with a margin of normal skin.
Adding to the details, there are certain specialized circumstances when more specific codes are best. These include site-specific skin biopsy codes for the nails, vermilion and mucosal lip, penis, vulva and external ear. These specialized codes take into account the additional complexity of biopsy at these sites and may better describe the procedure used than the standard codes.
Byline: Martha L. Sikes, MS, RPh, PA-C
Posted: August 30, 2016
Adapted from the original article.