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Code This!

Scenario Week of June 15, 2012:
View Current Scenario

Preoperative Diagnosis: Nevus, forearm

Postoperative Diagnosis: Same

Operation: Punch biopsy of nevus, forearm

Anesthesia: Local

Complications: None

Indications:
This 67-year-old woman presents for removal of a nevus of the left forearm that has recently changed in appearance.

Plan: punch biopsy.

Informed Consent:
The risks and benefits of the procedure were explained to the patient. The patient elected to proceed with the procedure(s).

Procedure:
The area was prepped with Betadine. A local anesthetic was injected around the area. A 4 mm skin punch was inserted into nevus, and a piece of the nevus was removed and sent to pathology. Minor bleeding was stopped by placing a 4 x 4 dressing over the site and applying pressure to the area. Once hemostasis was achieved, the area was cleaned with normal saline and a Band-Aid was applied.

Biopsy report received two days after this procedure confirms that the lesion is a blue nevus.

Code this!


Answers:

CPT PROCEDURES
11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Rationale:
Biopsy codes are used to report the removal of a small amount of tissue to determine the extent of a disease, confirm a diagnosis, or estimate the outcome of a disease. A single tissue sample may be lifted or picked out with forceps or a portion of the lesion may be biopsied by incising the lesion and applying sutures. Biopsy codes are appropriate for needle aspiration for biopsy, incisional biopsy, and partial excision, as well as for scraping, curetting, and using a skin punch.

Biopsy codes are arranged by anatomic site of the lesion or cyst. For this procedure—a punch biopsy of nevus, forearm—look in the CPT index, under the term “biopsy” where the subterms “skin lesion” refer you to code 11100–11101. When these codes are referenced in the integumentary section, code 11100 describes a biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion and code 11101 describes each separate/additional lesion. Since there was only one lesion biopsied, the appropriate code choice would be 11100.

ICD-9-CM DIAGNOSES
216.6 Benign neoplasm of skin of upper limb, including shoulder

Rationale:
In order to code to the highest level of specificity, the pathology report should be consulted before coding neoplasms. When coding neoplasms, the alphabetic index should always be consulted using the specified neoplasm as a main term because it provides specific coding instructions for that type of neoplasm such as morphology. For the nevus of the forearm, the instructions found in the alphabetic index under the main term “Nevus” indicate that any of the subterms included that are followed by a morphology code should be coded using the main term “Neoplasm” subterms “skin” and “benign”. When the subterm “blue” is located, it is noted that it is followed by a morphology code.

The next step would be to look under the term “neoplasm,” which would be found in ICD-9-CM alphabetic index. Neoplasms are listed in a table format, alphabetically by anatomical site, and further divided into six columns identifying the behavior as primary, secondary, or in situ malignancy, benign, uncertain behavior, or unspecified.

Because the instructional note found under “Nevus” instructed us to use the subterms skin and benign, the subterms “skin and “forearm” are located. Using the column “benign,” code 216.6 is referenced. When this code is verified in the ICD-9-CM tabular listing, it describes benign neoplasm of skin of upper limb, including shoulder which includes nevus.

 
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