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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Coding Corner - Jan/Feb 2010

February 1st, 2010

Coding biopsies - incisional v. excisional

Properly coding pathology and its treatment is a constant battle for the oral and maxillofacial surgery practice. This "Coding Corner" attempts to simplify and clarify the current concepts and coding options.

Practitioners are asked to evaluate and treat pathologic lesions of the oral and maxillofacial region on a daily basis. Therefore, it is incumbent on practitioners that the proper diagnosis and subsequent therapies are accurately conveyed to third party carriers.

This article examines the principles of coding biopsies, both intraoral soft tissue lesions and intraosseous lesions. At first glance it may appear quite simple, but actually coding the specific procedure can be quite daunting. The concept of a biopsy needs to be thought of as the partial removal of tissue in order to gain a pathologic diagnosis, while the excisional technique represents the removal of the entire lesion and should be coded accordingly. In the CPT world, an incisional biopsy is simply referred to as a "biopsy," while an excisional biopsy, simply as an "excision."

For example, a patient presents with a whitish plaque measuring 3.5 cm in diameter with irregular borders located in the mucobuccal fold adjacent to the mandibular incisors. Due to the size of the lesion the surgeon deems it necessary to stage the removal of this lesion over the course of several weeks. The first procedure would be an "incisional" biopsy technique described by CPT code 40808 (biopsy, vestibule of mouth). The specimen is immediately sent to the lab for analysis, but the claim form for reimbursement should be held until the pathology report is obtained. The codes on the claim form must reflect the findings of the final pathologic analysis. It would be inappropriate to report unspecified codes such as ICD-9-CM code 239.0 (neoplasm of unspecified nature; digestive system), uncertain behavior ICD-9-CM code 235.1 (neoplasm of uncertain behavior of digestive and respiratory systems; lip, oral cavity, and pharynx) or benign lesion ICD- 9-CM code 210.4 (benign neoplasm of other and unspecified parts of mouth) unless that code reflected the pathologist's findings after study. The second stage procedure, if performed using an "excisional" technique (and in this example via complex repair), would be reported with CPT code 40814 (excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair). Again, the diagnosis code(s) submitted should be determined after pathologic analysis. While holding the claim in this fashion may slow down the billing process, it does prevent reporting errors and represents best coding practice. Note that, in the above example, if both the incisional biopsy and related therapeutic excisional biopsy (or simply "excision") were performed during the same operative session, only the therapeutic procedure (excision) would be reported.

The same general principles hold true when treating intraosseous lesions of the mandible and maxilla. An example of this is a radiolucent lesion measuring 4.0 cm in diameter in the anterior maxilla not associated with any root apices. Most likely the treatment of this pathologic lesion would be staged in two parts over the course of several weeks. The first procedure will be a biopsy (incisional technique) reported with CPT code 20220 (biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs)) followed by the excisional technique with removal of the entire lesion. Depending upon the surgical technique required, either a curettage/enucleation described by CPT code 21030 (excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage) or the more extensive removal with osteotomies described by CPT code 21048 (excision of benign tumor or cyst of maxilla; requiring intraoral osteotomy (eg, locally aggressive or destructive lesion(s)) would be performed. Again, the diagnosis code reported would reflect the findings from the pathology report, and if the two procedures were performed during the same operative session, only the therapeutic procedure (excision) would be reported.

CPT includes soft tissue biopsy codes for many specific areas such as, but not limited to, the lip (40490), anterior two-thirds of the tongue (41100), floor of mouth (41108) and palate (42100). Also included in CPT are codes for intraosseous lesion biopsies. These may be found in the 20220 - 20245 range of CPT. The aforementioned are coined "biopsy" procedures in the CPT manual, which implies they are performed via an "incisional" technique. CPT codes for excisional biopsies are also broken down between soft tissue and intraosseous lesions. Examples of soft tissue lesion excision codes include those for the anterior two thirds of the tongue (41112), floor of mouth (41116) and palate (42104). Examples of intraosseous lesion excision codes include sites such as the mandible (21025, 21040, 21044, 21045, 21046 and 21047) and many more.

AAOMS offers several coding and billing courses to assist members with correct claim filing. For more information, visit the Coding Workshops page.