Topic 15: Clinical Coder: Lesion Excisions
Abstract: In the Integumentary section of the CPT code book, there are numerous codes listed for the removal of lesions (e.g., 11400 – 11646). In order to appropriately code the lesion excision procedure, you must know the: number of lesions excised, the morphology of the lesion(s), the anatomic location of the lesion(s), the dimension(s) of the lesion(s), and the techniques use to remove the lesion(s) and to repair the defect site(s) of the lesion(s). There are also codes available for the destruction (17000 –
17250), paring/cutting (11055 – 11057) and shaving (11300 – 11313) of lesions.
Morphology—Benign vs. Malignant:
Before coding, consult the pathology report to verify the morphology of the lesion.
Two different sets of codes exist in the integumentary system—one for benign lesions and one for malignant lesions. The codes assigned to excision of a malignant lesion differ from the code assigned to excision of a benign lesion since the physician has to excise several layers of skin and tissue, which can result in a more extensive wound.
Malignancy Site Re-Excision: Re-excision procedures performed to widen margins at subsequent operative sessions should be reported by using the appropriate code identifying the size, location and type of excision performed, and modifier ’58’ should be appended if performed during the postoperative period of the primary excision procedure.
For Example: A patient had a malignant 1.5 cm lesion excised from his leg at a previous operative session, and during the postoperative period, it was discovered that the malignancy had recurred and the margins were re-excised. The re-excision extended 1.0 cm. Code the re-excision as 11601 (excision of malignant lesion, 0.6 to 1.0 cm) with modifier ‘58’ appended. (Source: September 2003
CPT Assistant newsletter, AMA.)
Multiple Excisions to Remove Malignancies: If a frozen section pathology report comes back during the same operative session showing the margins of excision are not adequate and an additional excision is performed to remove the entire tumor, only one code should be reported based on the final widest excised diameter. Source:
November 2003 CPT Assistant newsletter, AMA.
Dimensions:

The excision code is determined by the diameter of the actual lesion—not the specimen sent to pathology. Measurements must be precise: Being off by just one millimeter can result in the selection of an incorrect code. When more than one dimension of a lesion is provided (e.g., a lesion is asymmetrical or irregular), indicate the largest side; for example, if a lesion’s dimensions are described as 2 x 1.2 x 0.5 cm, the lesion should be listed as 2 cm. (Source: CPT Assistant ,
Fall 1995, AMA; CPT Assistant newsletter, December 1998, page 10).


Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician’s judgment. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg with a skin graft).
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For malignant lesions , when frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600 – 11646, as appropriate. Append the modifier –58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure.
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Example, if a benign lesion of the trunk measures 1.0 cm and the margins required to adequately excise the lesion is 0.5 cm on both sides for a total margin of 1.0 cm, then you should add 1.0 cm + 0.5 cm + 0.5 cm = 2.0 cm. In this case, code 11402,
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 1.1 to 2.0 cm , should be reported to reflect the benign lesion and necessary margin excised from the trunk.
Source: “CPT 2003
Coding Symposium Questions and Answers” handout, November 14-15, 2002,
Chicago, IL, AMA.
Coding Tips:
The pathology report probably will give the size of the specimen, rather than the size of the lesion. However, you should code the size of the specimen only when the size of the lesion cannot be found in the operative report or elsewhere in the medical record.

Code 17106 classifies destruction of a lesion less than 10 sq cm. From a CPT coding perspective, the descriptor appropriately allows for reporting lesions measured as a “few mm” in size. It is not necessary to append reduced services modifier –52 when reporting code 17106 for lesion less than 10 sq cm. (Source: December 2000 CPT
Assistant newsletter, AMA).
Surgical Techniques:
Wide excision of a neoplasm involves the removal of the neoplasm, its capsule and a margin of normal tissue.

Radical resection is the removal of the neoplasm, its capsule and the entire section of the anatomic structure (muscle, fascia, tendon, bone) surrounding the growth (see
Musculoskeletal system codes as appropriate).
Destruction of Lesions:
See codes 17000 - 17250 for destruction of benign or premalignant lesions. Codes
17000 - 17004 specifically classify destruction of lesions other than skin tags and cutaneous vascular lesions.
Coding Tips:
•
Report codes 17000-17004 to classify destruction of condyloma in the perineal area. (Source: CPT Assistant newsletter, June 1999, page 10).
•
See codes 11200 and 11201 for destruction of skin tags. Since codes 11200 and
11201 are diagnostic-specific for removal of skin tags, and removal includes scissoring or
• any sharp method, these codes should be reported for removal of skin tags that have been
“shaved.” Source: November 2002
CPT Assistant newsletter, AMA.
Do not report 17004 in conjunction with 17000-17003.

Photodynamic Therapy: code 96567 describes the non-surgical treatment of nonhyperkeratotic actinic keratosis lesions of the face or scalp by a topical aminolevulinic acid. The photosensitizing agent is activated using the application of light. Code 96567 is not reported for each lesion treated, but rather per each phototherapy exposure session. Source: August 2003 CPT Assistant newsletter,
AMA.
 Mohs Surgery: The appropriate code to report should be based on the specific stage of Mohs surgery that is being performed during this encounter, even if previous stages were performed by another physician.
Example: A patient is referred to a physician after having four stages of Mohs surgery performed by another physician. This encounter should be coded as 17307
[Mohs surgery, additional stage(s)].
Source: November 2003 CPT Assistant newsletter, AMA.
Paring/Cutting:
Laterality not body location is a factor in reporting codes for paring or cutting (11055 -
11057. Source: CPT Assistant newsletter, December 1997, page 10
Shaving of epidermal or dermal lesions (see codes 11300–11313) includes chemical or electrocauterization of the wound (the wound does not require suture closure). Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full thickness dermal excision. Codes 11300 – 11313 are

defined by the technique used, and may be used for either benign or malignant lesions removed by shaving technique. (Source: CPT Assistant newsletter, February 2000, page
11).
Shaving of epidermal or dermal lesions (see codes 11300–11313) includes chemical or electrocauterization of the wound (the wound does not require suture closure).
Coding Tips:
•
Do not assign an excision of lesion code(s) when:
– a lesion is excised prior to adjacent tissue transfer or rearrangement (see codes
14000–14300);
– a lesion is excised from a skin graft recipient site prior to application of a skin graft (see code 15000).
•
•
When a lesion is removed from a previous mastectomy site, the site is considered the “trunk,” not “breast,” since the breast is no longer present.
When a malignant lesion has been excised and a reexcision is performed to ensure that the entire lesion has been removed, the code for excision of malignant lesion is assigned to the second procedure, even though the pathology report may indicate no further evidence of malignancy at the margins. According to the AMA, since the patient had a previous malignancy, this procedure should be coded as excision of a malignancy.
Multiple Lesions:
Some codes provide for excision of multiple lesions. Review code descriptions carefully. For example: The excision (ligation) of up to 15 skin tags would be indicated by one code (11200).
Wound Repair:
When excising lesions, physicians may create a wound that needs to be closed. Wound repairs are classified as simple, intermediate or complex. The code for excision of a lesion includes simple suturing of a superficial wound without significant involvement of deeper structures. An intermediate or complex closure after an excision should be coded separately.
Coding Tips
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The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately, in addition to the excision of benign or malignant lesion code.
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See also Clinical Coder: Wound Repair.

Skin Biopsy:
(Source: October 2004 CPT Assistant newsletter, AMA, Chicago, IL) :
During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not considered a separate biopsy procedure and is not separately reported.
The use of a biopsy procedure code (eg, 11100, 11101) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date, and are to be reported separately.
The intent of a biopsy is to remove a portion of skin, suspect lesion, or entire lesion so that it can be examined pathologically. The intent of an excision procedure is to remove the entire lesion along with a margin of normal tissue around it. Obtaining or removing the tissue in an excision procedure is part of the procedure itself, i.e., removing the lesion in this manner is the procedure. It is not considered a separate biopsy procedure; therefore, a biopsy code is not separately reported.
Coding Tips:

The impression that any procedure in which the specimen is sent to pathology is a biopsy is erroneous.

If the procedure narrative describes excision, the appropriate code that supports the documented method used for excision should be selected. If the documentation supports a biopsy, the appropriate code(s) from 11100-11101 should be reported.

The CPT coding system includes site-specific codes for a biopsy of select body areas. To conform to CPT guidelines that the most specific code should be used to identify a given service, codes 11100, 11101 are to be used if no site-specific code is available.

When a biopsy is performed on each of several different lesions or sites on the
same date, each biopsy may be reported separately, as appropriate. Code
11100 is used to report the biopsy of the first lesion and code 11101 is used to
report the biopsy of each additional separate lesions.

3.
4.
5.
6.
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In cases where a biopsy is performed on one lesion and another lesion is
excised, both the code for the biopsy (11100, 11101) and the appropriate code
for the excision may be reported. The biopsy on one lesion is not considered a
part of the other procedure performed on a different lesion on the same day.
Therefore, each procedure may be reported separately. To further support the
distinction, it is important to link the relevant diagnosis to each procedure on
the claim to indicate the specific reason each was performed. Modifier 59
should be appended to the biopsy code to indicate that this was a separate
procedure.
Lesion Excision Critical Coding Questions:
1. How many lesions were excised?
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2. What is/are the morphology of the lesion(s)?
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Where is/are the lesion(s) located?
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What is/are the dimension(s) of the lesion(s)?
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What surgical technique was used to excise the lesion(s)? a. Surgical excision b. Surgical excision prior to adjacent tissue transfer/rearrangement c. Surgical excision prior to skin graft application d. Destruction e. Shaving
What type of repair(s) was/were performed?
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