CPT Coding for Skin Biopsies: Diagnosing a Skin Lesion

In a previous article, we discussed actinic keratosis, the most common type of precancer, or premalignant skin lesion. Today we are taking a step back to look at skin lesions in general and all the different types. In addition, we explain how the different types of biopsies are performed to diagnose these skin lesions. Finally, you will learn the specifics on CPT coding for skin biopsies based on the documentation and coding guidelines.

Skin Lesions

A skin lesion is a general term used to describe any change in the skin surface, and it can occur on any area of the body, according to Aetna. A skin lesion may present with various characteristics including raised, flat, large, small, fluid-filled, or with color.

Skin lesions are pretty common, and the effects of sun exposure in our younger years can play a significant role in developing skin cancer as we get older. Everyone is at risk. Therefore, it is critically important to monitor for any skin changes and see a physician for an exam and a biopsy, if necessary.

Different Types of Skin Lesions

The 3 different types of lesions are benign, premalignant, and malignant.

Benign (Non-Cancerous) Lesions or Neoplasms

There are many types of benign skin lesions, or skin tumors, and they rarely turn into cancers. Common benign skin tumors include moles (nevi), seborrheic keratoses, skin tags (acrochordon), sebaceous cysts, corns, warts (verruca vulgaris), and callouses.

Premalignant (Precancerous) Lesions or Neoplasms

A premalignant lesion is a lesion that may become malignant in time or may be in the early stages of skin cancer. Examples of pre-malignant skin lesions include actinic keratosis, lentigo maligna, leukoplakia, and squamous cell carcinoma in-situ (Bowen’s disease).

Malignant (Cancerous) Lesions or Neoplasms

Malignant lesions, or skin cancers, are skin lesions that may destroy or invade surrounding tissues and may metastasize (spread) to other areas of the body, according to the American Society of Plastic Surgeons. These skin cancers involve the top layer of skin called the epidermis and are often due to excessive sun exposure.

Diagnosing the Type of Lesion

The earlier skin cancer is found, the easier it is to treat. Therefore, many physicians recommend patients perform skin self-exams about once a month to check for any changes in moles, blemishes, freckles, or other skin marks.

Changes in the size, shape, or color should be brought to the physician’s attention so they can take a medical history and perform a thorough physical examination.

Medical History and Physical Exam

During a physical examination, the physician will look at the symptoms and ask about any sun exposure history, including sunburns and tanning. The physician will also want to know any personal or family history of skin cancer. They will note the size, shape, color, and texture of the areas of concern and whether there is any bleeding, oozing, or crusting.

Other areas of the body may be examined for moles and spots associated with skin cancer. The physician may also feel the nearby lymph nodes for any lumps under the skin, as some skin cancers can spread to the lymph nodes.

If there is any suspected skin cancer, a primary physician may refer the patient to a dermatologist to perform their standard physical examination. The specialist may also perform a dermatoscopy (otherwise known as dermoscopy, epiluminescence microscopy [ELM], or surface microscopy) to see the skin spots more clearly.

A unique magnifying lens with a light on it, or dermatoscope, is used to look at the spot, and a digital photo may also be taken. This test aids in determining whether the spot is benign or malignant and allows the physician to find skin cancer early and hopefully without the need for a skin biopsy.

Skin Biopsies

If the physician does suspect skin cancer, an area of skin may be removed and sent to a lab to be looked at under a microscope. This is referred to as a skin biopsy. A diagnosis is made based on a pathologist’s examination of a sample of tissue taken from the patient’s lesion or tumor. In some cases, the entire tumor may need to be removed to cure the basal or squamous cell skin cancer, or the patient may need additional treatment.

The following short video explains a shave biopsy and a punch biopsy.

The video below covers an excision of a skin lesion.

Types of Skin Biopsies

The type of skin biopsy performed is determined according to the suspected type of skin cancer, the area of the body where it is located, the size, and other factors. There is usually a scar left after the biopsy, so the type may be important if it is in a visible area. A local anesthetic is injected into the area with a small needle.

According to the American Cancer Society, skin biopsies are performed using the following techniques:

Tangential Biopsy

A tangential biopsy is often called a shave biopsy. This technique involves removal by scoop, saucerization, or curette. A small surgical blade is used to remove a sample of epidermal tissue which may or may not include part of the underlying dermis. This is considered a partial-thickness biopsy, because only a portion sample of the skin or mucous membrane is taken. It does not involve the full thickness of the dermis and does not need a suture closure.

Punch Biopsy

In a punch biopsy, a tiny round tool that resembles a cookie cutter is used to remove a full-thickness cylindrical skin sample. A full-thickness biopsy penetrates the tissue deep in the dermis or lamina propria and into the subcutaneous or submucosal space. The edges of the site may or may not be stitched together.

Incisional and excisional biopsies

With an incisional biopsy, a sharp blade is used to remove a full-thickness sample with a wedge or vertical incision. The wound edges are often stitched together. An excisional biopsy may be performed to surgically remove the entire lesion along with some normal tissue around it.

Once a skin biopsy is done, it is sent to a lab where a pathologist will look at it under a microscope. Many times, the samples are sent to a dermatopathologist, who has special training in viewing skin samples. The sooner the results come back with diagnosis confirmation, treatment can begin.

CPT Coding for Skin Biopsies

Skin biopsy procedure codes are reported using CPT codes 11102, 11103, 11104, 11105, 11106, and 11107. These codes are used when a biopsy procedure is performed independently to obtain tissue solely for diagnostic histopathologic examination, or when it is performed with other unrelated or distinct procedures or services at same time.

These biopsy codes are described as:

• 11102, Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette) single lesion
• +11103, Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure)
• 11104, Punch biopsy of skin (including simple closure, when performed) single lesion
• +11105, Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)
• 11106, Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); single lesion
• +11107, Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)

According to CPT, when one biopsy technique is used on more than one lesion on the same patient during the same encounter, the base code is reported, followed by the add-on code for each additional biopsy performed.

For example:

• Two tangential biopsies are reported as 11102 x 1, 11103 x 1
• Three punch biopsies are reported as 11104 x 1, 11105 x 2
• Four incisional biopsies are reported as 11106 x 1, 11107 x 3

When more than one biopsy technique is performed on a patient during the same encounter, only one base code (11102, 11104, or 11106) should be assigned even if multiple different techniques are used. Determining which code is primary is based on whichever code number has the highest value.

For example, CPT 11106 has a higher value than 11104. Additional biopsies should be reported using the add-on codes (11103, 11105, or 11107).

If a punch biopsy is performed on one lesion and a tangential biopsy is performed on another lesion, we would report 11104 x 1, 11103 x 1. CPT 11104 is the base code for the punch biopsy, and 11103 is an add-on code to describe the tangential biopsy. CPT 11104 has the higher value, so it is reported first.

Coding Exercise

A patient presents to his dermatologist for evaluation of three suspicious lesions: one on the right upper arm, one on the left lower leg, and one on the trunk. The dermatologist diagnoses the lesion on the trunk as seborrheic keratosis, and the patient elects to have no treatment since it is benign and does not cause any discomfort. The two lesions on the right arm and left leg are suspected basal cell carcinoma, and the dermatologist performs a shave biopsy at each site to help make a definitive diagnosis.

CPT codes to be reported are: 11102, 11103

• 11102, Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette) single lesion
• +11103, Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure)

Be sure to read the instructional notes provided in CPT before selecting the appropriate code.

There was no treatment provided for the patient’s seborrheic keratosis, so it would be inappropriate to report for it.

A few things to keep in mind:

• A tangential biopsy does not involve the full thickness of the dermis and is not considered an excision. An excision may be performed to surgically remove the entire lesion along with some normal tissue around it. For complete lesion excision with margins, CPT codes from 11400-11646 should be reported based on the type of lesion (benign or malignant). These codes also include a biopsy.
• Removal of an epidermal or dermal lesion using a shave technique may be performed for therapeutic reasons using codes 11300-11313, and the documentation should indicate the purpose of the procedure.
• There are also some site-specific biopsy codes in CPT.
• There is no need to wait for a pathology report before submitting the code for a biopsy (i.e. tangential, punch, and incisional). The only time you should wait for the pathology report is when it involves an excisional biopsy, because the code will be based on what is in the report.

Conclusion

Skin lesions may start out as benign but may become malignant over time. The upside is that when skin cancer is caught early, treatment can be started, and the cancer can be cured. However, a skin biopsy is needed to determine the type of lesion before treatment can begin. When reporting for skin biopsies, you need to know the type of biopsy performed and the anatomic site. Remember that excision codes include the biopsy so they should not be reported separately.

** This post was reviewed and updated on December 21, 2021. **

I submitted this article to BC Advantage/www.billing-coding.com for their publication under the title, “When Is It a Benign Skin Lesion and When Is it More? A Biopsy May Tell Us.” It is reprinted here with their permission.

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