Biopsy vs. shave vs. destruction vs. excision

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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I treated a tumor on the back by means of a broad scoop using a shave technique to the level of the mid dermis. I did not curette the lesion because I suspected amelanotic melanoma. The diagnosis on the pathology report was “superficial multifocal basal cell carcinoma, completely excised.” Should I bill this as an excision?

No. By definition, an excision must extend through the full thickness of the dermis to the level of the subcutaneous tissue. Regardless of the fact that the pathologist used the words “completely excised,” a shave that remains within the dermis cannot be reported as an excision.

Although some may be tempted to report the procedure as a destruction, this is incorrect as well. The Integumentary section of the CPT manual defines destruction as the ablation of benign, premalignant, or malignant lesions by any method, but clarifying language indicates that while this would include curettage, electrosurgery, cryosurgery, or laser or chemical treatment, it would not include removal by means of a blade or surgical scissors.

If a shave technique is used, remains in the dermis, and your intent is to remove the lesion, report the procedure as a shave. Shave codes do not distinguish between benign and malignant lesions, and are reported using the size of the lesion itself, measured prior to the procedure.

If a shave technique is used, and your intent is to sample a portion of a lesion, report the procedure as a biopsy. When a suspected basal cell carcinoma is biopsied and curetted, the bill should be held until the pathology report is received. If the lesion proves to be a basal cell carcinoma, only the destruction is reported, using the size of the final curettage defect.

If your intent is removal, and complete removal of the lesion requires you to scoop through the full thickness of the dermis, to the level of the subcutaneous tissue, the procedure should be reported as an excision, using the diameter of the lesion plus the necessary margin, measured prior to the procedure.[pagebreak]

Example 1: A patient presents with a 1 cm keratotic nodule on the dorsal forearm. You use a blade to scoop under the lesion to the level of uninvolved fat. You include a 4 mm margin of normal skin to ensure

complete removal of the suspected squamous cell carcinoma. The lesion is allowed to heal by secondary intention. The pathology report reads: “Well-differentiated invasive squamous cell carcinoma, completely excised.”

As complete removal of this tumor required you to scoop to the level of the subcutaneous tissue, this should be reported as excision of a malignant lesion, using a diameter of 1.8 cm (the lesion plus the necessary margin).

Example 2: You sample a broad pigmented lesion on the cheek by shave technique.

Your intent is to sample the lesion, so this is reported as a biopsy.

Example 3: A patient presents with a 1.0 cm red keratotic plaque on the upper back. Your differential includes Bowen’s disease and irritated seborrheic keratosis. You remove the lesion by shave technique with a 3 mm margin, remaining in the dermis. Curettage is not performed. The pathologist issues a report of Bowen’s disease (squamous cell carcinoma in situ), completely excised.

The shave remained in the dermis, and no curettage was performed. This should be reported as a 1 cm shave. Shave codes do not distinguish between benign and malignant lesions. They are based on the size of the lesion itself and do not include the margin.

More details on using destruction codes will appear in next month’s column.