Should we always wait for the pathology report before submitting a code for a biopsy?
No, not always.
Only for excisional biopsies, which are coded based on the pathology report. These codes describe excisional biopsies of benign lesions in the code series 11400 to 11446 and excisional biopsies of malignant lesions in the code series 11600 to 11646.
The claim for any other type of biopsy may be submitted on the date the service is performed.
- shave biopsies
- breast biopsies
- fine needle aspirations (new codes in 2019)
- punch, incisional, and tangential biopsies (new codes in 2019)
- and any other biopsies except those listed above.
It is only necessary to wait for the pathology report for the excisional biopsies, listed above, because the CPT® code is dependent on the diagnosis.
In Principles of CPT® Coding there are two other situations described in which it is not necessary to wait for the pathology report.
The first is if the lesion being excised is clearly benign, it is permissible to submit the claim using the excision of benign lesion codes.
And second, for a re-excision of a malignant lesion, report the CPT® codes for excisional biopsy of a malignant lesion, even if the margins are negative. In that case, if it is a re-excision of a malignant lesion, the claim can be submitted at the time services performed without waiting for the pathology report.
Reviewed, Betsy Nicoletti 10/11/2018