June 28, 2024
By: Ashely Harless
Biopsy vs Removal: A better understanding
I was in an AAPC workshop with several doctors once, and when we reached integumentary day, biopsy vs. removal became a hot topic. The instructor knew I specialized in dermatologic coding and turned the conversation over to me. I was scared that I oversimplified my answer with pretty much a one-word explanation, but it really does boil down to one word, “intent.” This topic can be quite confusing and frustrating for many people (providers included), so it comes up a lot more than you might think. Let’s get into the nuances a bit.
Biopsy vs Removal: Basics
The largest distinction between biopsy vs. removal lies in intent. Did the provider intend to take a sample for diagnostic purposes? Or was the intention to remove and treat the lesion?
It is true that when performing a biopsy, a provider may get the entire lesion. However, if the intent was simply to test a sample and the provider happened to get it all, this would still be coded as a biopsy.
Contradictory terms such as “shave removal biopsy” or “excisional biopsy” will only obscure documenting the provider’s intent. Therefore, these terms should be avoided. Even in conversation, they require further clarification to know what codes should be or should have been chosen. When selecting a code, the technique and clearly documented intent is critical.
Consider the following: Biopsy by Shave Method would be coded using 11102-11103; whereas a Shave Removal of a benign lesion would be coded as 11300-11313.
Per the AMA CPT book:
- A biopsy is the procedure to obtain tissue solely for diagnostic histopathologic examination.
- Shave removal is the therapeutic shaving of epidermal and dermal lesion and entire lesion is removed.
- An excision is the entire removal of a lesion, including margins, through the dermis.
- Destruction is another type of removal and is defined as the ablation of the lesion with electrosurgery, cryosurgery, laser or chemical treatment.
Biopsy vs. Destruction
Often, in dermatology, we will have notes that say, “biopsy by shave method with destruction.” I evaluate coding for this procedure virtually every day. I am sure if you are auditing dermatology or any notes of someone who performs these types of procedures, it is common for you as well.
This is where the provider takes a biopsy to send for pathology but then removes the lesion with electrodesiccation and curettage. Talk about confusing! This may seem to negate everything I just said, but it doesn’t (I promise). Since there is only one lesion, you may not bill for a shave, biopsy, and destruction. You may only use one code to represent the treatment of a lesion.
In our practice:
- The provider should hold billing for pathology results.
- If the path returns benign and treated, we code it as a biopsy. (11102-11103)
- If the path comes back as malignant and treated, we code it as malignant destruction. (17260-17286)
- If the path comes back as malignant but needs further treatment (excision or Mohs surgery), we code it as a biopsy and schedule a separate appointment for treatment.
Initially, I was excited when I was asked to write this week’s tip on this subject. I have had this conversation several times in dermatology over the last two decades and thought this would be a breeze. Then, that old fear crept in that I was oversimplifying with my favorite word, “intent.” This philosophy isn’t just my own. The American Academy of Dermatology and the Inga Ellzey Institute (where I received my dermatology coding education) teach that not only choosing these codes but also auditing them is based on the provider’s intent.
As coders and auditors, we cannot read providers’ minds. We are not even in the room when the procedure is done. Consequently, it is always good to understand the differences between the methods, especially if we need to educate providers on documentation and code selection. When in doubt, ask them, “What was your intent?”
Ashley Harless, CDC
Source: AMA CPT 2024 Professional Edition
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