fibrocutaneous coding

In family practice, skin biopsies are generally a shave biopsy or a full thickness biopsy. A shave biopsy is a shallow scraping of the skin done with a sharp blade held nearly horizontal to the skin. The resulting skin defect is very shallow and is often treated with a chemical or electrocautery to control bleeding. In contrast, a full thickness biopsy involves cutting into the deeper layers of the skin. Usually, the resulting defect requires a suture or two for closure. This type of biopsy is often done with a scalpel or a special punch biopsy tool. A wedge or plug of the skin is removed and sent for pathology evaluation. Biopsies requiring suture closure are coded using either 11100Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion or +11101 Each separate/additional lesion (List separately in addition to code for primary procedure) for the additional biopsies, and the shave biopsies would be coded with the CPT® 11300-11313 series of codes.

If a biopsy is part of another procedure, the biopsy code is not separately coded. For example, if a biopsy is part of a 1.1 cm neoplastic lesion excision on the forearm, only the excision code CPT® 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm is billed.

Family practitioners frequently treat skin conditions that require skin incision and drainage of fluid (pus, blood, or serous fluid). These procedures are referred to as incision and drainage (I&D). I&D implies a sharp instrument (e.g., a scalpel blade) is used to

open the skin and material is drained or removed. In most cases, the wound is irrigated and thoroughly cleaned before applying a dressing. Larger wounds may require the insertion and changing of packing daily, to allow the wound to drain and close before the skin edges heal over the wound cavity. The two codes covering most I&D services in family practice are CPT® 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single and 10061 complicated or multiple. Multiple lesions, or any lesion that requires progressive re-packing in the office or the management of systemic antibiotic therapy, could be considered complicated. There are separate I&D codes in the CPT® Surgery Section for foreign bodies, hematomas, puncture aspiration, and pilonidal cysts.

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