Do I need a pathology report to choose the appropriate code?

Answer: The pathology report will help in choosing the correct ICD/diagnosis code. Whether the report affects your procedure code depends on whether you’re reporting a biopsy or excision. The report will not determine which biopsy code you should choose because biopsy codes don’t differ based on the nature of the lesion.

In most cases, however, the pathology report will help in identifying the appropriate excision code because those codes do differ based on whether the lesion is benign or malignant. For instance, note the term “benign” in 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less).
What questions do you have about reporting biopsy or excision of a skin lesion? Let us know your answer in the comments section below.