Biopsies/Excisions; 11300-11313

AUDITING & COMPLIANCE TIP

Auditing for Biopsies vs. Excisions
Sara San Pedro, CPC, CEMC, CCP-P, AHIMA ICD-10-CM/PCS trainer, and AHIMA
Approved ICD-10 Ambassador

In the current world of regulatory reviews, RAC auditors have included in their reviews excision and biopsy coding. If the documentation does not contain enough detail or use the right terminology, it may be difficult to rebut if a RAC auditor deems the procedure should be down coded or a full refund is requested. Terms such as "shave biopsy removal" and "incisional biopsy" could be interpreted as a biopsy when in fact the provider removed the entire mole but used a shave technique to accomplish it. It is very important that the documentation reflect the extent of the procedure and that the person assigning the codes understands the terminology the provider is using and requests clarification or addendums in the documentation when ambiguous terms are used.

First off, we need to know the difference between an excision and a biopsy. An excision is a procedure that is intended to fully remove a lesion. There is usually the lesion itself and the surgical margins. Per CPT, to qualify as a lesion, the removal must be full thickness, meaning it extends through the dermis into the fat. A biopsy procedure is one where a sample of anything less than the full lesion is obtained even if that sample extends through the dermis and into the fat. Completely removing the lesion does not necessarily mean that an excision is coded if the removal does not extend through the dermal layer. If the removal of the lesion or mole is less than full thickness, then a shave removal code may be more appropriate (CPT 11300-11313).

Medical necessity can come into play when reporting an excision versus a biopsy as well. It may be deemed not medically necessary upon a regulatory review to remove and code an excision procedure when a more minimally invasive procedure such as a biopsy or shave removal is appropriate. For example, a condition such as seborrheic keratosis, which is a superficial skin condition, would not necessarily require a full-thickness removal. If the provider chooses to routinely do full-thickness excisions to remove superficial lesions such as these or other conditions affecting only the epidermal or dermal layer of the skin, and bill for them as benign skin lesion excisions, they could run the risk of a necessity review. Despite documentation of the depth extending through the dermis and that the entire lesion was removed, the medical necessity of doing the removal to that extent would need to be clearly substantiated in the medical record as this could be deemed by medical review as excessive.

There are many areas in coding for skin procedures where coders and providers can get tripped up or misunderstand and therefore misuse codes to describe the work that was done. Reviewing the guidelines for reporting and ensuring that documentation is robust and complete will go a long way in insulating you from payer and government scrutiny down the road.