Attention all surgeons: in coding, there is no such thing as an excisional biopsy. Say what? In Current Procedural Terminology (CPT), the coding book used by all U.S. insurers, including Medicare, one can code for the excision or the biopsy. A lesion that is excised and then sent for pathologic diagnosis is an excision of that lesion — not a biopsy.

In ophthalmic coding, different sections of the CPT are used in addition to Eye, most often Integumentary and also Musculoskeletal. Biopsies used in ophthalmic coding draw principally from Eye and Integumentary.

In 2019, there appears to be a major revision in biopsy coding, and this review is dedicated to making the new guidelines available and understandable.

The CPT Codes¹

New CPT codes for 2019 are prefaced with a red dot new instructions are in green between triangles + indicates an add-on code; and # indicates out of numerical sequence.

The following tips may be helpful when reading a descriptor and applying it.

• The parent code descriptor is aligned with the code number to the left and begins with a capital letter.
• The parent code descriptor ends at the semicolon (;).
• Any further descriptor attached to the parent code applies to the parent code only.
• The first indent is a child code, is indented to the parent code, and begins with a lowercase letter.

The actual description of the child code is the description of the parent code up to the semi-colon and all the description in the indented code.

11102	Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion
+11103	each separate/additional lesion (List separately in addition to the code for the primary procedure)
	(Report 11103 in conjunction with 11102, 11104, 11106, when different biopsy techniques are performed to sample separate/additional lesions for each type of biopsy technique used)
11104	Punch biopsy of skin (including simple closure, when performed); single lesion
+11105	each separate/additional lesion (List separately in addition to the code for the primary procedure)
	(Report 11105 in conjunction with 11104, 11106, when different biopsy techniques are performed to sample separate/additional lesions for each type of biopsy technique used)
11106	Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion
+11107	each separate/additional lesion (List separately in addition to the code for the primary procedure)
	(Report 11107 in conjunction with 11106)
#67810	Incisional biopsy of eyelid skin including lid margin
	(For biopsy of skin of the eyelid, see 11102, 11103, 11104, 11105, 11106, 11107)

For 2019 CPT codes physician reimbursement, 11106 and 67810 pay the same amount: NonFacility = $153.57 and Facility = $62.73 as national averages.

For 2019 ASC reimbursement, 11106 is priced $112.07 and 67810 is priced at $132.25.

New CPT Instructions for Biopsies^1,2

The following instructions are taken directly from the Integumentary System instructions in CPT 2019.

“The use of a biopsy procedure code (eg, 11102, 11103, 11104, 11105, 11106, 11107) indicates that the procedure to obtain tissue solely for diagnostic histopathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Biopsies performed on different lesions or different sites on the same date of service may be reported separately, as they are not considered components of other procedures.

During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported.

Partial-thickness biopsies are those that sample a portion of the thickness of skin or mucous membrane and do not penetrate below the dermis or the lamina propria. Full-thickness biopsies penetrate into tissue deep to the dermis or lamina propria, into the subcutaneous or sub-mucosal space.

Sampling of stratum corneum only, by any modality (eg, skin scraping, tape stripping) does not constitute a skin biopsy procedure and is not separately reportable.

An appropriate biopsy technique is selected based on optimal tissue-sampling considerations for the type of neoplastic, inflammatory, or other lesion requiring a tissue diagnosis. Biopsy of the skin is reported under three distinct techniques:

Tangential biopsy (eg, shave, scoop, saucerize, curette) is performed with a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel, or curette to remove a sample of epidermal tissue with or without portions of underlying dermis. The intent of a tangential biopsy (11102, 11103) is to obtain a tissue sample from a lesion for the purpose of diagnostic pathologic examination. Biopsy of lesions by tangential technique (11102, 11103) is not considered an excision. Tangential biopsy technique may be represented by a superficial sample and does not involve the full thickness of the dermis, which could result in portions of the lesion remaining in the deepest layers of the dermis.

For therapeutic removal of epidermal or dermal lesion(s) using shave technique, see 11300-11313.

An indication for a shave removal (11300-11313) procedure may include a symptomatic lesion that rubs on waistband or bra, or any other reason why an elevated lesion is being completely removed with the shave technique, suggesting a therapeutic intent. It is the responsibility of the physician or qualified healthcare professional performing the procedure to clearly indicate the purpose of the procedure.

Punch biopsy requires a punch tool to remove a full-thickness cylindrical sample of skin. The intent of a punch biopsy (11104, 11105) is to obtain a cylindrical tissue sample of a cutaneous lesion for the purpose of diagnostic pathologic examination. Simple closure of the defect is included in the service. Manipulation of the biopsy defect to improve wound approximation is included in the simple closure.

Incisional biopsy requires the use of a sharp blade (not a punch tool) to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating deep to the dermis, into the subcutaneous space. The intent of an incisional biopsy (11106, 11107) is to obtain a full-thickness tissue sample of a skin lesion for the purpose of diagnostic pathologic examination. This type of biopsy may sample subcutaneous fat, as would be done in the evaluation of panniculitis. Although closure is usually performed on incisional biopsies, simple closure is not separately reported.

(For complete lesion excision with margins, see 11400-11646.)

When multiple biopsy techniques are performed during the same encounter, only one primary lesion biopsy code (11102, 11104, 11106) is reported. Additional biopsy codes should be selected based on the following convention:

If multiple biopsies of the same type are performed, the primary code for that biopsy should be used along with the corresponding add-on code(s).

If an incisional biopsy is performed, report 11106 in combination with a tangential (11103), punch (11105), or incisional biopsy (11107) for the additional biopsy procedures.

If a punch biopsy is performed, report 11104 in combination with a tangential (11103) for the additional tangential procedures.

If multiple tangential biopsies are performed, report tangential biopsy (11102) in combination with 11103 for additional tangential biopsy procedures.

When two or more biopsies of the same technique (i.e., tangential, punch, or incisional) are performed on separate/additional lesions, use the appropriate add-on code (11103, 11105, 11107) to specify each additional biopsy. When two or three different biopsy techniques (i.e., tangential, punch, and/or incisional) are performed to sample separate/additional lesions, select the appropriate biopsy code (11102, 11104, 11106) plus an additional add-on code (11103, 11105, 11107) for each additional biopsy performed.

The following table provides an illustration of the appropriate use of these codes for multiple biopsies:

Procedures Performed	CPT Code(s) Reported
2 tangential biopsies	11102 x 1, 11103 x 1
3 punch biopsies	11104 x 1, 11105 x 2
2 incisional biopsies	11106 x 1, 11107 x 1
1 incisional biopsy, 1 tangential biopsy, and 1 punch biopsy	11106 x 1, 11103 x 1, 11105 x 1
1 punch biopsy and 2 tangential biopsies	11104 x 1, 11103 x 2

The following parenthetical notes the most pertinent codes for ophthalmic biopsies and ophthalmic plastic surgery are listed below.

(For biopsy of lip, use 40490)

(For biopsy of vestibule of the mouth, use 40808)

(For biopsy of tongue, anterior two-thirds, use 41100)

(For biopsy of floor of the mouth, use 41108)

(For biopsy of eyelid skin including lid margin, use 67810)³

(For biopsy of conjunctiva, use 68100)“

Narrative descriptions of the procedures may be found in CPT Changes. (See references 2 and 3).

Conclusion

This is a confusing subject for surgeons, let alone office managers, billing personnel, and ASC surgical coders. Listservs are replete with questions on how to code a biopsy. It is the responsibility of the surgeon to master these codes and send the proper codes to the ASCs and the practice.

I highly recommend the purchase of the 2019 CPT and the 2019 CPT Changes. The latter is replete with clinical examples of the new CPT codes. ■

CPT codes copyrighted 2018, The American Medical Association. All Rights Reserved.

References

1. Current Procedural Terminology (CPT^®) Professional Edition. American Medical Association. 2019.
2. CPT Changes 2019: An Insider’s View. American Medical Association. 2019; 31-35, 77.
3. CPT Changes 2013: An Insider’s View. American Medical Association. 2013; 160-161.