Biopsy – Skin Nevus Medical Specialty: Dermatology
Description:
Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.
PREOPERATIVE DIAGNOSES:
- Left back skin nevus2 cm.
- Right mid back skin nevus1 cm.
- Right shoulder skin nevus2.5 cm.
- Actinic keratosis left lateral nasal skin2.5 cm.
POSTOPERATIVE DIAGNOSES:
- Left back skin nevus 2 cm.
- Right mid back skin nevus 1 cm.
- Right shoulder skin nevus 2.5 cm.
- Actinic keratosis, left lateralnasal skin, 2.5 cm.
PATHOLOGY: Pending.
TITLE OF PROCEDURES:
- Excisional biopsy of left back skin nevus 2 cm, two-layer plastic closure.
- Excisional biopsy of mid-back skin nevus 1 cm, one-layer plastic closure.
- Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.
- Trichloroacetic acid treatment to left lateral nasal skin 2.5 cmto treat actinic keratosis.
ANESTHESIA:
Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.
BLOOD LOSS:
Actinic keratosis, left lateral nasal skin, 2.5 cm.
COMPLICATIONS:
None.
PROCEDURE:
Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps, and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin suture, the skin was closed in the subcuticular plane, and then the skin was closed at the level of the skin with a 4-0 nylon interrupted suture.
Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel, and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked, and a 15-blade scalpel was used to make an elliptical incision into the skin.
Next, the skin was grasped with a small Bishop forceps, and curved Iris scissors were used to dissect the skin ellipse and remove the skin. The skin was undermined with the curved Iris scissors, and then radio frequency treatment was used for hemostasis.
Next, the subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, a trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to the separate operative report for details. The patient tolerated this procedure very well, and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.
Excisional Biopsy: Skin Nevus With Chemical Treatment
Identify the Procedures Performed
First, review the operative report. The physician excised a 2 cm nevus on the left back with a two-layer closure and a 1 cm nevus on the right mid-back with a simple closure. In addition, the physician excised a 2.5 cm nevus on the right shoulder with a two-layer closure. Finally, the physician used trichloroacetic acid to chemically destroy an actinic keratosis on the left lateral nose.
Key guidelines for students: When the provider completely removes a lesion, code an excision, not a biopsy. Also, simple closure is included in the excision codes. However, you may report an intermediate repair separately when the provider performs a layered closure.
CPT Coding for a Skin Nevus Biopsy
Excision of Benign Lesions
Nevi are benign lesions, and these are on the trunk and upper extremity. Therefore, use CPT codes 11400 through 11406.
Left back nevus (2 cm), trunk: 11402, excision of a benign lesion including margins, trunk, arms, or legs, 1.1 to 2.0 cm. The two-layer closure makes this lesion eligible for an intermediate repair.
Right mid-back nevus (1 cm), trunk: 11401, excision of a benign lesion on the trunk, arms, or legs, 0.6 to 1.0 cm. The provider describes a single layer closure. As a result, it is a simple closure, and the excision code includes it.
Right shoulder nevus (2.5 cm), upper extremity: 11403, excision of a benign lesion on the trunk, arms, or legs, 2.1 to 3.0 cm. Again, the layered closure makes this lesion eligible for an intermediate repair.
Intermediate Repair (Layered Closure)
The provider describes layered closures for the left back lesion and the right shoulder lesion. Intermediate repair codes for the trunk and extremities come from 12031 through 12037. Next, add the lengths: 2 cm for the left back plus 2.5 cm for the right shoulder equals 4.5 cm. Because repairs of the same classification and anatomic group are summed, you report one code.
12032 Intermediate repair of wounds of scalp, axillae, trunk and/or extremities, 2.6 cm to 7.5 cm
Actinic Keratosis Treatment
The physician performed a chemical destruction with trichloroacetic acid. In other words, this is a destruction of a premalignant lesion.
17000 Destruction of premalignant lesion (eg, cryosurgery, chemosurgery), first lesion
The provider treated only one lesion, so you report a single unit.
ICD-10-CM Coding
Skin Nevus (Melanocytic Nevus)
For the back lesions, report D22.5 Melanocytic nevi of trunk. For the shoulder lesion, report D22.61 Melanocytic nevi of right upper limb, including shoulder. Note that D22.6 requires a fifth character for laterality.
Actinic Keratosis
L57.0 Actinic keratosis
HCPCS
The documentation supports no separately reportable HCPCS codes. For example, the local anesthetic (Xylocaine with epinephrine) is bundled into the procedure.
Final Codes
- CPT: 11402, 11401, 11403, 12032, 17000
- ICD-10-CM: D22.5, D22.61, L57.0
- HCPCS: None
Key Points
If the provider fully removes a lesion, report an excision code, even if the report says “biopsy.” Also, the excised diameter, including margins, determines the CPT code. Do not code simple repairs separately. However, you may report intermediate repairs when the provider documents a layered closure, and you add together repairs of the same classification and anatomic group. Finally, chemical destruction with trichloroacetic acid qualifies for CPT 17000 when the provider treats actinic keratosis.
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