Many medical practices perform skin procedures. A patient may see a dermatologist, a family physician or a surgeon when the time comes to find out, “What’s this thing growing on my arm?” This article discusses excision of benign and malignant lesions. Shaves, biopsies, and destruction of lesions are covered in other articles.
Per CPT, excision of benign lesions includes simple closure and local anesthesia. CPT defines excision as “full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.
When coding for excision of skin lesions (not shave, biopsy or destruction) a coder must know three things:
- type of lesion (benign or malignant)
- location of the lesion and the size of the excision
- type and size of repair in the event the repair is reportable
Accurate code selection requires knowing these.
| Types of lesion | Benign | Malignant |
| Neoplasms | Basal cell carcinoma | |
| Cicatricial (scars) | Squamous cell carcinoma | |
| Fibroma (superficial) | Melanoma | |
| Cutaneous lipoma | ||
| Inflammatory lesions | ||
| Congenital lesions | ||
| Cystic | ||
| Location | Trunk, arms, legs | |
| Scalp, neck, hands, feet, genitalia | ||
| Face, ears, eyelids, nose, lips, mucous membrane | ||
| Size of excision | Measure the size of the excision prior to the excision and use the size of the widest clinical diameter of the lesion and the narrowest margin | |
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