Coding for physician work associated with skin biopsies (e.g. CPT codes 11100 or 11101)
Skin biopsy procedures are frequently needed to confirm the nature of a presenting clinical problem. In other instances, suspicious lesions are encountered in the course of a skin examination, which may be unrelated to the presenting problem. In either case, the physician work involved for these procedures is separate from the evaluation and management services.
The physician pre-service work will include: discussion of the probable diagnoses and indication for the biopsy procedure, risks and benefits; description of the biopsy procedure method, and expected result or scar. In addition, a patient agreement/informed consent must be obtained and staff must be advised for preparation of patient and necessary anesthetic, supplies and instrument tray preparation.
The intra-service work can include: inspection and palpation of the lesion to assess depth and to select the most representative lesion or site to obtain the specimen; cleansing of the biopsy site with suitable antiseptic; injection of appropriate local anesthetic; scrubbing and gloving by physician; application of sterile drape; obtain skin specimen with scalpel, skin punch or suitable instrument, depending on depth and amount of tissue needed; collection of specimen in labeled container; undermine wound edges as needed to facilitate repair; suture as necessary to approximate wound edges or achieve hemostasis with pressure, chemical or electrocautery, or application of topical hemostatic agents, e.g. Gelfoam or Surgicel; application of Steri-Strips or antibiotic ointment and sterile dressing.
The post-service work can include: instruction of the patient and/or family on postoperative wound care, dressing changes and follow-up; patient advised about how to recognize significant complication, e.g. bleeding or allergic reaction to antibiotic ointment or adhesive dressing; patient advised when results will be available and how they will be communicated; completion of medical records; and communication of results to referring physician as appropriate.