A dermatologist performed 3 incisional biopsies and 1 tangential bx.
So, I billed Horizon: 11106x1, 11107x2 and 11103x1.
Horizon paid for 11106 but denied 11107x2 and 11103 stating that 11107 and 11103 are mutually exclusive. Is this true? FindACode Editor disagrees but i need a specific coding rule to appeal to Horizon.I always followed the table found on page 94 of the 2021 CPT manual which seems to be saying that only one main primary/even numbered bx code and the rest has to be add-on codes. Is this right or not? Please help. Thank you
Take a look at the CPT guidelines and the description to find your answers, instead of using 11103 for the tangential biopsy you should report 11102 for the first single tangential biopsy.
The incisional biopsies may be correct if the sites are different 11106 for the first one and 11107 (add-on code) for any additional.
If your sites are different:
X1 Incisional 11106 reports incisional biopsy of a single skin lesion.
X2 Incisional 11107 reports incision biopsy of each separate/additional lesion.
X1 Tangential 11102 reports a single lesion removed by tangential skin biopsy and code 11103 reports each additional lesion.
CPT Codebook Guidelines (Pg 93 CPT 2021)
“The use of a biopsy procedure code (eg, 11102, 11103, 11104, 11105, 11106, 11107) indicates that the procedure to obtain tissue solely for diagnostic histopathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Biopsies performed on different lesions or different sites on the same date of service may be reported separately, as they are not considered components of other procedures.”