When can I bill a biopsy in conjunction with another procedure?

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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A biopsy may be billed in conjunction with another procedure if it relates to a separate and distinct lesion or a separate patient encounter. In these instances, the 59 modifier should be appended to override the Correct Coding Initiative (CCI) edit that might otherwise bundle the procedures.

Example: You sample a portion of a suspected basal cell carcinoma by means of shave technique, curette the base of the lesion, and send the specimen to the lab.

This was a single lesion, so it would be inappropriate to report shave, biopsy, and destruction of the same lesion. In order to receive the full reimbursement for the medically necessary services you provided, wait until the pathology report is received. If the report confirms that the lesion was a basal cell carcinoma, report only destruction of the malignant lesion. The correct diameter to report is the final diameter of the curettage defect.

If, on the other hand, the report confirms that this was merely a pearly benign melanocytic nevus, report only the biopsy as this was the medically necessary service. As your intent was to sample a portion of the lesion, you should use the skin biopsy code rather than a shave code. Shave codes are used when your intent is removal of the lesion while remaining in the dermis.

In some instances, it is appropriate to report both the biopsy and definitive procedure for the same lesion when certain circumstances are met:

  • 1) The lesion must not have been biopsied previously or the report must not be available.
  • 2) The biopsy must be interpreted prior to the definitive procedure, and
  • 3) The interpretation must determine the subsequent procedure.

A common example outside of our specialty is that Medicare would pay for a breast biopsy done for diagnosis of breast cancer followed immediately by lumpectomy or mastectomy. [pagebreak]

Other examples relevant to dermatology:

1. You are preparing to do Mohs surgery on a nasal basal cell carcinoma, but notice a separate pearly papule on the adjacent cheek. You biopsy the cheek lesion, frozen section interpretation confirms the diagnosis of an infiltrative basal cell carcinoma, and you perform Mohs surgery on both lesions.

The biopsy (11100-59) and frozen section pathology (88331-59) should be reported in addition to Mohs surgery. In this case, all criteria are met, as the lesion had not been biopsied previously, the biopsy was interpreted prior to the definitive procedure, and the interpretation determined the subsequent procedure.

2. You biopsy and curette a suspected basal cell carcinoma and send the specimen to the lab.

It would be inappropriate to bill both the biopsy and the destruction, as the biopsy specimen was not interpreted prior to the definitive procedure and did not determine the definitive procedure. You curetted based on your clinical suspicion, as the biopsy had not yet been read. In this case, you should wait for the pathology report to confirm the diagnosis and bill only the destruction if the biopsy confirms the diagnosis of basal cell carcinoma.