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.
The physician pre-service work will include obtaining pertinent history from the patient, including: Previous skin cancer, prior treatment history, sun protection history, etc.
Discussion with the patient will include: Indication for biopsy procedure, risks, and benefits; description of biopsy procedure method, and expected result and/or scarring. In addition, the patient agreement/informed consent is obtained and staff is 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 the 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 fact the patient is “new” to the provider is not sufficient alone to justify reporting an E/M service on the same DOS as a minor surgical procedure.
— NCCI V19.2
The post-service work can include: Instruction of the patient and/or family on postoperative wound care, dressing changes and follow-up; patient advisory about how to recognize significant complication, e.g. bleeding or allergic reaction to antibiotic ointment or adhesive dressing; patient advisory when results will be available and how they will be communicated; completion of medical records; and communication of results to referring physician as appropriate.
According to NCCI, modifier 25 can be appended to an E/M service code when reported with minor surgical procedures or procedures not covered by global surgery rules to indicate that the E/M service is separate and significantly identifiable from other services reported on the same date of service. Because all procedures include pre-, intra- and post-procedural work that is inherent in the procedure, providers must not report an E/M service code for this work.
However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.
Though the statements above indicate that the E/M service is included in the minor procedure, it does not preclude one from reporting a separate E/M service — when performed and accurately documented. E/M documentation must indicate that the E/M service was above and beyond the procedure and, upon review, must stand on its own merit to support the level of service reported.