Benign and Malignant Skin Biopsies Excisions Melody Draper

Benign and Malignant Skin Biopsies & Excisions Melody Draper Hnatovic March 30, 2019

Melody Draper Hnatovic, RHIT, CHPS, CCS Melody is the HIM Supervisor and Privacy Officer for Jefferson Healthcare in Port Townsend, WA. She has over 36 years in HIM and coding experience and is an AHIMA approved ICD-CM/PCS trainer.

Goals Distinguish when to code biopsy vs. excision vs. destruction Explore new 2019 CPT biopsy codes and the hierarchies Review coding rules for benign and malignant lesions procedures MOHS procedures Case examples References

CPT disclaimer “CPT” is a registered trademark of the American Medical Association. Their codes, descriptions and manual content are copyright by the AMA. All rights are reserved by the AMA. This information has been abbreviated for a focused presentation for a specific audience. Verify all codes and information in a current CPT book. This information is considered current at the time of this presentation but may change throughout the year. Please check for current guidance on the CMS and Noridian websites. This presentation does not provide legal or billing advice.

Biopsy vs. Excision Biopsy A sampling from a lesion to provide a specimen for cytologic or histopathologic examination for diagnostic purposes. Fine needle aspiration (FNA) Excision Complete removal of the lesion and submitted for histopathologic examination for diagnostic purposes. Core needle Saucerization (Deep scoop shave) Tangential Excision Punch Incisional Superficial shave

Biopsy Techniques Fine Needle Aspiration Material is aspirated with a fine needle for cytological examination May be performed with our without imaging guidance New for 2019 - Imaging is now included in the CPT code Core Needle biopsy Performed with a larger bore needle for histopathological examination

New 2019 Fine Needle Biopsy Codes 10021 Fine Needle aspiration biopsy, without imaging guidance, first lesion +10004 each additional lesion 10005 Fine needle aspiration biopsy, including ultrasound guidance, first lesion +10006 each additional lesion 10007 Fine needle aspiration biopsy, including fluoroscopic guidance, first lesion +10008 10009 Fine needle aspiration biopsy, including CT guidance, first lesion +10010 10011 each additional lesion Fine needle aspiration biopsy, including MR guidance, first lesion +10012 each additional lesion

New 2019 Biopsy Codes 11102 Tangential Biopsy +11103 11104 Punch Biopsy +11105 11106 each separate/additional lesion Incisional Biopsy +11107 each separate/additional lesion

Anatomy of the Skin https: //www. aad. org/public/kids/skin/the-layers-of-your-skin American Academy of Dermatology

Biopsy Techniques Tangential biopsy Includes shave, superficial scoop, saucerization or curette Performed with a sharp blade, scalpel or curette Does not involve the full thickness of the dermis. Punch biopsy Requires a punch tool Removes full thickness cylindrical sample of skin Simple closure is included Incisional biopsy Requires the use of a sharp blade Removes full thickness sample of the skin via vertical incision or wedge Penetrates deep into the subcutaneous space and may sample subcutaneous fat Simple closure is include https: //www. medifee. com/surgery/skin-cancer-surgery-in-indiaj http: //northlandent. blogspot. com/2012/06/how-to-do-punch-biopsy. html http: //oralmaxillo-facialsurgery. blogspot. com/2010/05/oral-punch-biopsy-and-scalpel-biopsy. html

Rules and Hierarchy Multiple lesions biopsied by different methods (11102 -11106) Only one primary code should be reported, followed by additional add-on codes for subsequent biopsies Multiple biopsies of the same type performed, use primary code for that biopsy in addition to the corresponding add-on code(s) Hierarchy Incisional biopsy takes precedence over punch and tangential biopsies The primary punch biopsy takes precedence over the primary tangential Incisional Punch Tangential

Multiple Biopsies Examples Incisional biopsy & tangential biopsy & punch biopsy separate lesions 11106, +11103, +11105 Punch biopsy & tangential biopsy separate lesions 11104, +11103

2 tangential biopsies, separate lesions 11102 X 1 (primary), 11103 X 1 (additional)

2 tangential biopsies, separate lesions 11102 X 1 (primary), 11103 X 1 (additional) 3 punch biopsies, separate lesions 11104 X 1 (primary), 11105 X 2 (additional)

2 tangential biopsies, separate lesions 11102 X 1 (primary), 11103 X 1 (additional) 3 punch biopsies, separate lesions 11104 X 1 (primary), 11105 X 2 (additional) 2 incisional biopsies, separate lesions 11106 X 1 (primary), 11107 X 1 (additional)

2 tangential biopsies, separate lesions 11102 X 1 (primary), 11103 X 1(additional) 3 punch biopsies, separate lesions 11104 X 1 (primary), 11105 X 2 (additional) 2 incisional biopsies, separate lesions 11106 X 1 (primary), 11107 X 1 (additional) 1 incisional biopsy, 2 punch biopsy, 3 tangential biopsies, separate lesions 11106 X 1 (primary), 11105 X 2 (additional, 11103 X 3 (additional)

Benign Neoplasms Dermatofibroma Epidermoid cyst Cherry angioma Seborrheic keratosis Sebaceous gland hyperplasia Nevus Hyperkeratotic papilloma

Malignant Neoplasms Melanoma Basal cell carcinoma Squamous cell carcinoma Kaposi sarcoma Merkel cell carcinoma Lymphoma of skin

Excision lesions Benign & Malignant 11400 -11446 Excision lesions, Benign 11600 -11646 Excision lesions, Malignant Full-thickness of lesion including margins Anatomical location of the lesion Trunk, arms legs Scalp, neck, hands, feet, genitalia Face, ears, eyelids, nose, lips, mucous membrane Measured prior to excision Includes local anesthesia Includes simple non-layered closure Report separately, appropriate intermediate (12031 -12057) or complex (13100 -13153) closures

Measurement of Lesions https: //www. facs. org/~/media/files/publications/bulletin/2003%20 february%20 bulletin. ashx

Excision Lesions Excision benign lesion of the neck 1. 0 cm X 2. 0 cm + margin 0. 4 cm = 2. 4 cm with simple repair 11423

Excision Lesions Excision benign lesion of the neck 1. 0 cm X 2. 0 cm + margin 0. 4 cm = 2. 4 cm with simple repair 11423 Excision malignant lesion of the nose 0. 9 cm + 0. 6 cm margin = 1. 5 cm 11642

Excision Lesions Excision benign lesion of the neck 1. 0 cm X 2. 0 cm + margin 0. 4 cm = 2. 4 cm with simple repair 11423 Excision malignant lesion of the nose 0. 9 cm + 0. 6 cm margin = 1. 5 cm 11642 Excision malignant lesion of the back 1. 0 X 3. 0 cm + 0. 6 cm margin = 3. 6 cm with intermediate closure 11604, 12032

Destruction Techniques Laser surgery Electrosurgery Cryosurgery Chemosurgery Surgical curettement Destruction benign or premalignant lesions 17000 -17111 Destruction malignant lesions 17260 -17286 measured by diameter of lesion https: //www. aafp. org/afp/2012/1215/p 1118. html

Mohs Micrographic Surgery A surgical procedure used to treat skin cancer. Individual layers of cancer tissue are removed and examined under a microscope one at a time until all cancer tissue has been removed. Also called Mohs surgery. CPT Codes 17311 -17315 https: //www. cancer. gov/publications/dictionaries/cancer-terms/def/mohs-micrographic-surgery

Mohs 17311 Mohs micrographic technique, head, neck, hands, feet, genitalia, first stage, up to 5 tissue blocks +17312 each additional stage, up to 5 tissue blocks 17313 Mohs micrographic technique, trunk, arms or legs first stage, up to 5 tissue blocks +17314 each additional stage, up to 5 tissue blocks +17315 Mohs micrographic technique, each additional block after the first 5 tissue blocks, any stage

More rules to remember When a lesion is biopsied and then removed by destruction or excision, code only the excision or destruction of the lesion, do not code the biopsy Therapeutic lesion removal by shave technique is coded to 11300 -11313 (example: symptomatic lesion that rubs on waistband or bra and is completely removed by shave technique Mohs Unlike other skin lesion excisions, all repairs may be coded separately If a suspected skin cancer biopsy is performed, same day as Mohs, report the appropriate diagnostic skin biopsy code (11102, 11104, 11106) with modifier -59

Documentation Requirements Type of lesion(s) Suspicious lesion, neoplasm benign, malignant Number of lesions biopsied or excised Location of the lesions of skin Technique used FNA, with or without imaging guidance Multiple lesions different imaging modalities, same day, same session add -59 modifier Tangential, punch, incisional Excisional Diameter of lesions plus margins Intermediate or complex repair and length of defect repaired Destruction Benign or premalignant or malignant Mohs Micrographic surgery How many stages and blocks

Let’s test your skills! Scenario # 1 Shave biopsy 5 mm lesion left eyebrow 11102

Let’s test your skills! Scenario # 1 Shave biopsy 5 mm lesion left eyebrow 11102 Scenario #2 Suspicious lesion right leg punch biopsied and separate lesion identified as actinic keratosis left cheek treated with destruction by liquid nitrogen 11104, 17000

Let’s test your skills! Scenario # 1 Shave biopsy 5 mm lesion left eyebrow 11102 Scenario #2 Suspicious lesion punch right leg biopsied and separate lesion identified as actinic keratosis left cheek treated with destruction with liquid nitrogen 11104, 17000 Scenario #3 Shave biopsy right hand X 2 lesions, 1 punch biopsy left arm lesion, incisional biopsies of lesions right arm and left hand 11106, +11107, +11103 X 2, +11105

Having Fun? Scenario # 4 Excision malignant lesion scalp measuring 1. 0 X 2. 0 cm with 0. 4 cm margins 1. 0 X 2. 0 + 0. 4 = 2. 4 11623

Having Fun? Scenario # 4 Excision malignant lesion scalp measuring 1. 0 X 2. 0 cm with 0. 4 cm margins 1. 0 X 2. 0 + 0. 4 = 2. 4 11623 Scenario #5 Basal cell carcinoma right cheek treated with Mohs first stage with 4 blocks of tissues not clear of cancer cells. Second stage with 7 tissue blocks clear of cancer cells 17311, 17312, 17315 X 2

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References CPT 2019 professional edition. (2019). Chicago, IL: American Medical Association. CPT Assistant, November 2006 Pages: 1 -7 Category: Mohs Micrographic Surgery CPT Assistant, February 2008 Page: 8 Category: Coding Consultation Surgery: Integumentary System