Choosing the correct biopsy code can be a difficult task. Even determining whether a procedure is actually a biopsy at all can be a challenge. If you have seen your fair share of integumentary procedure notes, you know that getting to the correct code can be tough.
We commonly see notes that seem to indicate an excision was done, yet the note also states it was a biopsy. What code should you use?
Maybe you’ve seen a tangential biopsy note that also resembles a shave removal procedure. These are two different procedures that are represented by two different codes, so which one should you use?
Fortunately, the guidelines provide lots of instructions to point us in the right direction. Ask yourself, “What was the intent of the procedure?” Does it fit the CPT definition of a biopsy which is a “procedure to obtain tissue solely for diagnostic histopathologic examination….independently or was unrelated or distinct from other procedures/services provided at the time?” Or was it done for therapeutic reasons?
Going back to the scenario of a shave removal note that also looks a lot like a tangential biopsy note.
What was the intent? Was the lesion shaved and removed due to the lesion frequently catching on clothing, causing pain and bleeding? If so, this would lend itself to being a therapeutic procedure and a shave removal code would be appropriate. Or was it an odd-looking lesion that is biopsied utilizing a shave method and sent to pathology to determine a diagnosis? This would be a tangential biopsy.
Intent is just one thing to consider when it comes to determining the correct code to use. Want to dive a little deeper? Be sure to check out Haugen’s Biopsy Procedures Webinar where we will also discuss biopsy techniques and using depth to get to the right code.
Looking for additional information on this topic?
Emily Lomaquahu, CPC, CPMA, CEDC
Senior Coding Quality Auditor & Educator
Emily is a Senior Coding Quality Auditor for Haugen Consulting Group and brings over a decade of experience to the profee team! She began her career as an auditor and with her keen eye for detail, she quickly found it was a perfect fit. Emily thrives in a collaborative environment and enjoys creating high-quality trainings to help providers and coders navigate charts and improve their accuracy. She earned a bachelor’s degree from the University of Colorado, in Denver. Emily specializes in Evaluation and Management (E/M), Primary Care, Anesthesia, Emergency Department, and Neurology, though she says Anesthesia and Neurology are her favorites! She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and Certified Emergency Department Coder (CEDC).