How To Use CPT Code 11102

CPT 11102 refers to a tangential biopsy of a single skin lesion using methods such as shave, scoop, saucerize, or curette. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 11102 procedures.

1. What is CPT 11102?

CPT 11102 is a medical code used to describe a specific type of skin biopsy procedure. This code is used by medical professionals to document and bill for the tangential biopsy of a single skin lesion using various techniques such as shave, scoop, saucerize, or curette. The procedure is typically performed to diagnose and treat various skin conditions and abnormalities.

2. 11102 CPT code description

The official description of CPT code 11102 is: “Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion.”

3. Procedure

The CPT 11102 procedure involves the following steps:

1. The patient is properly prepared and anesthetized, typically with local anesthesia.
2. The provider uses a flexible blade to shave off the portion of the lesion that is above the level of the surrounding skin.
3. Alternatively, the provider may use a similar blade but hold it so that it is bent into an arc, passing the blade through the thicker inner layer of the skin and possibly into subcutaneous tissue to remove a vesicular or bullous lesion, keeping the capsule intact.
4. Additionally, the provider may use an angled scalpel or a curette, a spoon or scoop-shaped surgical instrument, to scrape a lesion from the skin.
5. Sutures are generally not needed for this type of biopsy.
6. The provider places an adhesive bandage and sends the specimen to the pathology lab for analysis.

4. Qualifying circumstances

Patients eligible to receive CPT code 11102 services are those who present with a single skin lesion that requires a tangential biopsy for diagnostic or treatment purposes. This may include patients with suspicious moles, growths, or other skin abnormalities that need further examination and analysis by a pathologist. The decision to perform a tangential biopsy using CPT 11102 is typically based on the provider’s clinical judgment and the patient’s medical history and presentation.

5. When to use CPT code 11102

It is appropriate to bill the 11102 CPT code when a provider performs a tangential biopsy of a single skin lesion using one of the specified techniques (shave, scoop, saucerize, or curette). This code should be used for the initial lesion only. If additional lesions are biopsied during the same session, the appropriate add-on code (+11103) should be used for each additional lesion.

6. Documentation requirements

To support a claim for CPT 11102, the following information should be documented in the patient’s medical record:

• Patient’s medical history and presentation, including the presence of a single skin lesion requiring biopsy.
• Physical examination findings, including the size, location, and appearance of the lesion.
• Provider’s clinical judgment and rationale for performing a tangential biopsy using one of the specified techniques.
• Details of the procedure, including the technique used, anesthesia administered, and any complications encountered.
• Pathology report with the analysis of the biopsied specimen.

7. Billing guidelines

When billing for CPT code 11102, it is important to follow the appropriate guidelines and rules to ensure accurate reimbursement. Some key points to consider include:

• Use CPT 11102 for the initial lesion only. If additional lesions are biopsied during the same session, use the add-on code +11103 for each additional lesion.
• Ensure that the patient’s medical record contains the necessary documentation to support the claim, as outlined in the documentation requirements section.
• Be aware of any payer-specific guidelines or requirements that may apply to the billing of CPT 11102.

8. Historical information

CPT 11102 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Similar codes to CPT 11102

There are several other codes related to skin biopsies that differentiate from CPT 11102 in various ways:

• CPT 11104: This code is used for punch biopsies of skin lesions, which involve the use of a circular cutting instrument to remove a cylindrical sample of tissue.
• +11105: This add-on code is used for each additional punch biopsy of a skin lesion during the same session.
• CPT 11106: This code is used for incisional biopsies of skin lesions, which involve the removal of a portion of the lesion using a scalpel or other cutting instrument.
• +11107: This add-on code is used for each additional incisional biopsy of a skin lesion during the same session.
• +11103: As mentioned earlier, this add-on code is used for each additional tangential biopsy of a skin lesion during the same session as CPT 11102.

10. Examples

Here are 10 detailed examples of CPT code 11102 procedures:

1. A patient presents with a suspicious mole on their arm. The provider performs a tangential shave biopsy using a flexible blade to remove the mole for analysis.
2. A patient has a raised, scaly lesion on their leg. The provider uses a curette to scrape the lesion from the skin and sends the specimen for pathology examination.
3. A patient with a history of skin cancer has a new growth on their back. The provider performs a saucerization biopsy to remove the lesion and submit it for analysis.
4. A patient presents with a vesicular lesion on their chest. The provider performs a tangential biopsy using an arced blade to remove the lesion while keeping the capsule intact.
5. A patient has a single skin lesion on their face that requires biopsy. The provider uses a scoop technique to remove the lesion and sends it for pathology review.
6. A patient with a history of sun exposure has a suspicious lesion on their shoulder. The provider performs a tangential shave biopsy to remove the lesion for further examination.
7. A patient presents with a single skin lesion on their abdomen. The provider uses a curette to perform a tangential biopsy and submits the specimen for analysis.
8. A patient has a single bullous lesion on their foot. The provider performs a tangential biopsy using an arced blade to remove the lesion while preserving the capsule.
9. A patient with a single skin lesion on their neck undergoes a tangential biopsy using a saucerization technique. The provider removes the lesion and sends it for pathology review.
10. A patient presents with a single skin lesion on their scalp. The provider performs a tangential shave biopsy using a flexible blade to remove the lesion for further examination.