In a previous article, we discussed actinic keratosis, the most common type of precancer, or premalignant lesion. Today we are taking a step back to look at skin lesions and biopsy procedures to make a diagnosis.

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

Types of 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.

The 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.

diagram of 3 main types of malignant skin lesions

Malignant Skin Lesions

According to the American Cancer Society, the three main types of malignant skin lesions, or skin cancer, are basal cell carcinoma, squamous cell carcinoma, and melanoma.

  • Basal Cell Carcinoma (BCC) is the most common type of skin cancer, occurring in about 8 out of 10 skin cancers. These cancers involve the basal cell layer of the epidermis, which is the lower part of the epidermis, and usually develop on the face, head, and neck. They can also occur in other areas of the body. Although they rarely spread, if left untreated, they can invade the bone or other tissues beneath the skin. Without complete removal, they can recur, and often new ones appear in other areas.

Basal cell carcinomas may present as:

    • Firm, flat, yellow, or pale areas that look like a scar
    • Red patches that are raised and may be itchy
    • Small red or pink pearly bumps that are shiny and translucent that may have brown, black, or blue areas
    • Growths that have raised edges with an area in the middle that is lower and pink in color. These growths may consist of abnormal blood vessels that spread out in various directions.

Basal cell cancers may bleed after a minor injury or shaving. If it does not heal within a few weeks, it may be an indication of BCC.

  • Squamous cell carcinoma (SCC) occurs in about 2 out of 10 cases of skin cancer and involves the outer part of the epidermis. These cancers usually develop on the face, ears, neck, lip, and back of the hands, although they can occur in scars or chronic skin sores in other areas of the body. They can also begin as actinic keratosis, a precancerous skin condition. In some cases, SCCs can develop in the genital area, but this is less common.

Squamous cell carcinomas may present as:

    • Red patches that are rough or scaly and may bleed or crust
    • Growths or lumps that are raised and may have a lower area in the middle
    • Open sores that may ooze or crust and fail to heal, or they heal and return
    • Wart-type growths

Basal and squamous cell cancers may also form as a flat area with very little change in the normal skin. These skin cancers and other types can vary in their appearance from the symptoms provided above, which is why it is important that a physician examine the skin whenever there is concern.

  • Melanoma is a skin cancer that is much less common than basal and squamous cell carcinomas. Melanoma starts in the melanocytes, the pigment-making skin cells. Although melanomas can appear anywhere on the skin, the trunk (chest and back) is the most common area where they appear first in men. In women, the legs are the most common first site of occurrence. Other common sites are the neck and face. Melanomas can also start in the eyes, mouth, intestines, and genital and anal areas, but this is much less common than on the skin.

According to the National Cancer Institute, melanomas may present as:

    • Asymmetrical in shape where one side does not match the other side
    • Irregular borders where the edges are ragged, notched, or blurred
    • Uneven color which may include black, brown, tan, white, gray, red, pink, or blue
    • Larger in size than previously but can also be very small
    • Different in some way over the past few weeks or months

A sign of advanced melanoma is a change in the texture of the mole and a breakdown in the skin surface that may look scraped, hard, or lumpy. In some cases, the melanoma may be itchy, tender, or painful, and the skin surface may bleed or ooze.

Other Types of (Malignant) Skin Cancer

Other types of skin cancer that are less common than melanoma, basal cell carcinoma, and squamous cell carcinoma include Merkel cell carcinoma, cutaneous (skin) lymphoma, Kaposi sarcoma, skin adnexal tumors that begin in the hair follicles or skin glands, and various types of sarcomas.

Combined, these types of skin cancer occur in fewer than 1% of all skin cancers and are treated differently than basal carcinoma, squamous cell carcinoma, and melanoma.

Diagnosis

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 he or she 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 history of sun exposure to include sunburns and tanning. The physician will also want to know of any personal or family history of skin cancer. He or she 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 that may be 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 who may perform his or her own 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 special 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 not only aids in determining whether the spot is benign or malignant, but it also allows the physician to find skin cancer early, and hopefully without the need for a skin biopsy.

Skin Biopsy

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 additional treatment may be needed.

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. Often called a shave biopsy, this technique also 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. 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.

Lymph Node Biopsy

Basal and squamous cell carcinomas rarely spread beyond the skin, but when they do, they typically spread to the nearby lymph nodes first. Melanomas can also spread to the lymph nodes and quickly, so if the physician feels the lymph nodes and they seem too large or firm, a lymph node biopsy may be necessary to determine if the cancer has spread to them.

The types of lymph node biopsies include:

  • Fine needle aspiration (FNA) biopsy. A local anesthetic may be used to numb the area, and then a syringe with a thin, hollow needle is used to remove small fragments of the lymph node. There is rarely much discomfort and there is no scar left. This type of biopsy is not as invasive as some others but may result in a sample that is too small to find cancer cells.
  • Surgical (excisional) lymph node biopsy. This method is used when cancer is suspected to have spread to the lymph node but is not found in the FNA biopsy. The lymph node is surgically removed and examined in a physician’s office or in an outpatient surgical center using local anesthesia. A small scar will be left.
  • Sentinel node biopsy. Used to evaluate melanoma, a radioactive solution or blue dye is injected into one or more lymph nodes to see which sentinel nodes turn blue. These nodes are then removed and tested to see if they contain melanoma cancer cells.

Besides the lymph nodes, melanomas can spread to other organs of the body. Therefore, additional imaging tests may be performed to determine the possible spread. Once melanoma has been diagnosed, the stage of the cancer will be determined based on how serious the cancer is and to determine the best course of treatment.

skin biopsy procedure codes in CPT

CPT Coding

Skin biopsy procedure codes are reported using CPT 11102, 11103, 11104, 11105, 11106, and 11107. These codes replaced CPT codes 11100 and 11101, effective January 1, 2019 and 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 Example

Let’s look at this coding example:

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. When reporting for skin biopsies, you need to know the type of removal performed and the anatomic site. Remember that excision codes include the biopsy so they should not be reported separately.

doctor looking at patient's skin before taking skin biopsy


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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