Punch 1/25/2017. Coding for Biopsies. Jeffrey D. Lehrman, DPM, FASPS, FACFAS, MAPWCA. APMA Coding Committee. Editorial Advisory Board, WOUNDS
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1 Coding for Biopsies Jeffrey D. Lehrman, DPM, FASPS, FACFAS, MAPWCA APMA Coding Committee Editorial Advisory Board, WOUNDS Board of Directors, American Society of Podiatric Surgeons Board of Directors, American Professional Wound Care Association Fellow, American Academy of Podiatric Practice Management Punch Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion Punch, Curette, Scissors If do multiple punches Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure) Add-on code 1
2 Example 3 Punch Biopsies x 2 units Shave Shave, Legs Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm 2
3 Shave, Feet Shaving of epidermal or dermal lesion, single diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single diameter over 2.0 cm Diagnoses Benign, Skin D22.7- Melanocytic nevi of lower limb, including hip (need laterality) D04.7- Carcinoma in situ of skin of lower limb, including D23.7- Other benign neoplasm of skin of lower limb, including CODES NOT COMPLETE NEED LATERALITY Diagnoses Malignant, Skin C43.7- Malignant melanoma of lower limb, including D03.7- Melanoma in situ of lower limb, including hip (need laterality) CODES NOT COMPLETE NEED LATERALITY 3
4 KP C46.0 Kaposi's sarcoma of skin Can t Find Your Diagnosis L98.8 Other specified disorders of the skin and subcutaneous tissue Have no patience D48.5 Neoplasm of uncertain behavior of skin 4
5 11755 Biopsy of nail unit CPT Assistant 2002: Entire Nail Unit Not a clipping of the nail D04.7- Carcinoma in situ of skin of lower limb, including L60.3 Nail dystrophy D48.5 Neoplasm of uncertain behavior of skin Biopsy By Aspiration Ganglion, Adipose, Cyst Fine needle aspiration; without imaging guidance Fine needle aspiration; with imaging guidance Biopsy By Aspiration - Diagnoses Have Diagnosis M Ganglion (cyst), ankle and foot (need laterality) D21.2- Benign neoplasm of connective and other soft tissue of lower limb, including C49.2- Malignant neoplasm of connective and soft tissue of lower limb, including hip (need laterality) Inpatient D48.1 Neoplasm of uncertain behavior of connective and other soft tissue 5
6 Bone Biopsy Biopsy, bone, trocar, or needle; superficial Biopsy, bone, open; superficial Bone Biopsy Diagnosis Codes M86.1- Acute osteomyelitis M86.2- Subacute osteomyelitis M86.3- Chronic multifocal osteomyelitis M86.4- Chronic osteomyelitis with draining sinus M86.5- Other chronic hematogenous osteomyelitis M86.6- Other chronic osteomyelitis CODES NOT COMPLETE NEED MORE CHARACTERS!!! Bone Biopsy Diagnosis Codes D16.3- Benign neoplasm of short bones of lower limb (need laterality) C40.3- Malignant neoplasm of short bones of lower limb (need laterality) C40.8- Malignant neoplasm of overlapping sites of bone and articular cartilage of limb (need laterality) D48.0- Neoplasm of uncertain behavior of bone and articular cartilage (need laterality) CODES NOT COMPLETE NEED LATERALITY 6
7 Thank You!! Coding for Biopsies Jeffrey D. Lehrman, DPM, FASPS, FACFAS, MAPWCA Editorial Advisory Board, WOUNDS Board of Directors, American Society of Podiatric Surgeons Board of Directors, American Professional Wound Care Association APMA Coding Committee Fellow, American Academy of Podiatric Practice Management 7
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