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Coding for biopsy | Should we wait for a pathology report?

Question:

Should we always wait for the pathology report before submitting a code for a biopsy?

Answer:

Sometimes.

Wait for the pathology report only for excision of benign or malignant lesions, which are coded based on the pathology report. These codes describe excision of benign lesions in the code series 11400 to 11446 and excision of malignant lesions in the code series 11600 to 11646.

The claim for any other type of biopsy may be submitted on the date the service is performed.

This includes:

  • shave biopsies
  • breast biopsies
  • fine needle aspirations (new codes in 2019)
  • punch, incisional, and tangential biopsies (new codes in 2019)
  • and any other biopsies except those listed above.

It is only necessary to wait for the pathology report for the excision of lesions, listed above, because the CPT® code is dependent on the diagnosis.

In Principles of CPT® Coding there are two other situations described in which it is not necessary to wait for the pathology report.

The first is if the lesion being excised is clearly benign, it is permissible to submit the claim using the excision of benign lesion codes.

And second, for a re-excision of a malignant lesion, report the CPT® codes for excision of a malignant lesion, even if the margins are negative. In that case, if it is a re-excision of a malignant lesion, the claim can be submitted at the time services performed without waiting for the pathology report.

 

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Relevant Search Terms: coding for biopsy

Last revised August 18, 2021 - Betsy Nicoletti
Tags: general surgery_diagnosis coding, minor procedures

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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