Incisions, Excisions, and Destructions Accurate Reporting of Biopsies

While this may seem simplistic, the best way to begin a discussion of biopsies is with a definition of the term. Stedman’s Medical Dictionary defines a biopsy as the “removal and examination, usually microscopic, of tissue from the living body, often to determine whether a tumor is malignant or benign; biopsies are also done for diagnosis of disease processes such as infections.” The term may be used to describe either the procedure being performed, or the sample of tissue obtained. Biopsy procedures performed in a dental practice are primarily classified as either incisional or excisional. Also, a specimen may be obtained by collecting cells from the mucosa.

In this article we will review the most common types of biopsy procedures and how to accurately report each for insurance reimbursement. In discussing how to report a biopsy, we will use the term to refer to a procedure.

Many practices ask whether biopsies should be filed to medical or to dental first. Biopsies and treatments of suspicious lesions are usually considered medical in nature and should be filed to the patient’s medical plan(s) first. Claims may also be submitted to dental plans; however, these are often returned with a request that the claim be filed to the patient’s medical plan first. Keep in mind, if your office is contracted with any dental PPO plans, you may be required to report this procedure to dental even if no reimbursement is expected.

Whether a claim is submitted to a dental or a medical payer, it is important to report the most accurate code to describe the procedure performed. As previously noted, these procedures are considered medical in nature; therefore, all medical payers will require a Current Procedural Terminology (CPT) code to be reported on a medical claim form. For each of the biopsy procedures reviewed in this article, both dental and medical procedure codes are provided.

Incisional Biopsy

In an incisional biopsy, a small sample of tissue is taken from a suspicious lesion. This tissue is then sent to a pathology laboratory for microscopic examination. Based on the pathologist’s report, additional surgery may be scheduled for definitive treatment to remove the lesion.

The sample may be taken using a scalpel, a punch instrument, or a laser. The method used to obtain the specimen is not relevant to the procedure code reported or the fee charged. An additional fee may not be billed to the payer or the patient for the use of a laser.

CDT Codes

There are two dental codes for an incisional biopsy of oral tissue. The correct dental code to report is based on whether the biopsy was taken of soft tissue (e.g., mucosa or submucosa) or hard tissue (e.g., bone or tooth).

D7285 Incisional biopsy of oral tissue – hard (bone, tooth)

For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is not used for apicoectomy/periradicular surgery. This procedure does not entail an excision.

D7286 Incisional biopsy of oral tissue – soft

For partial removal of an architecturally intact specimen only. This procedure is not used at the same time as codes for apicoectomy/periradicular curettage. This procedure does not entail an

CPT Codes

When reporting a biopsy to a medical payer, the procedure code reported is based on the anatomical location of the lesion. Therefore, there are many more procedure codes from which to choose. Medical procedure codes applicable to incisional biopsy of oral tissue include, but are not limited to:

40490 Biopsy of lip

40808 Biopsy, vestibule of mouth

(CPT guidelines define vestibule of the mouth as the oral cavity outside the dentoalveolar structures. It includes mucosal and submucosal tissue of lips and cheeks.)

41100 Biopsy of tongue, anterior twothirds

41105 Biopsy of tongue, posterior onethird

41108 Biopsy of floor of mouth

42100 Biopsy of palate, uvula

20220 Biopsy, bone, trocar, or needle; superficial

Excisional Biopsy

An excisional biopsy is the removal of the entire lesion. This may be performed as definitive treatment following a previous incisional biopsy or as an initial procedure. Tissue removed during the procedure is often sent to a pathology lab for examination. Tissue removal is a component of the procedure; therefore, an additional biopsy procedure is not reported separately for the same lesion on the same date of service.

CDT Codes

Applicable dental codes are based on the size of the lesion, the complexity of the biopsy procedure, and whether the lesion is benign or malignant. Although dental payers rarely reimburse these procedures, CDT codes that may be reported include, but are not limited to:

Soft Tissue Lesions:

D7410 Excision of benign lesion up to 1.25 cm

D7411 Excision of benign lesion greater than 1.25 cm

D7412 Excision of benign lesion, complicated. Requires extensive undermining with advancement or rotational flap closure.

D7413 Excision of malignant lesion up to 1.25 cm

D7414 Excision of malignant lesion greater than 1.25 cm

D7415 Excision of malignant lesion, complicated. Requires extensive undermining with advancement or rotational flap closure.

Intra-Osseous Lesions:

D7440 Excision of malignant tumor – lesion diameter up to 1.25 cm

D7441 Excision of malignant tumor – lesion diameter greater than 1.25 cm

D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm

D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm

D7460 Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm

D7461 Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm

CPT Codes

Medical codes reporting the excision of a lesion are based primarily on the location of the lesion and if a repair was required to close the incision. Codes that may be reported to medical payers include, but are not limited to:

40810 Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair

40812 Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair

41110 Excision of lesion of tongue without closure

41112 Excision of lesion of tongue with closure; anterior two-thirds

41113 Excision of lesion of tongue with closure; posterior one-third

21030 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage

21040 Excision of benign tumor or cyst of mandible, by enucleation and/ or curettage

41825 Excision of lesion or tumor dentoalveolar structures; without repair (This code may be used to report an odontogenic or nonodontogenic cyst or tumor.)

41826 Excision of lesion or tumor dentoalveolar structures, with simple repair (This code may be used to report an odontogenic or nonodontogenic cyst or tumor.)

Biopsy by Collection of Cells

CDT Codes

The following are the two dental codes describing the collection of cells for microscopic examination:

D7287 Exfoliative cytological sample collection, For collection of non-transepithelial cytology sample via mild scraping of the oral mucosa.

D7288 Brush biopsy – transepithelial sample collection,For collection of oral disaggregated transepithelial cells via rotational brushing of the oral mucosa.

CPT Codes

No comparable CPT codes exist to report these collection procedures to medical payers. Some payers may allow an unlisted code to be reported. Alternatively, others may allow reporting a handling charge for the collection of the sample. Codes reported may be payer specific and include, but are not limited to:

40899 Unlisted procedure, vestibule of mouth

99000 Handling and/or conveyance of specimen for transfer from the office to a laboratory

Destruction of Lesions

The final procedure to be discussed is the destruction of a lesion. This is not actually a biopsy, since no tissue is collected, but is appropriately included here as a common procedure for the treatment of lesions.

CDT Codes

The dental code to report this procedure is:

D7465 Destruction of lesion(s) by physical or chemical method, by report. Examples include using cryo, laser or electro surgery.

CPT Codes

As with other procedures, the medical code to report the destruction of a lesion is based on the anatomical location of the lesion. Appropriate codes include, but are not limited to:

40820 Destruction of lesion or scar of vestibule of mouth by physical methods (e.g., laser, thermal, cryo, chemical)

42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical)

Diagnoses Codes

Thus far, only procedure codes have been discussed. Any discussion of pathology coding would be incomplete without a mention of selecting the proper diagnosis code to report. The purpose of a diagnosis code is to explain why a procedure is performed. All medical payers require at least one diagnosis code to process a claim. Some dental payers may also require a diagnosis code to be reported on the 2012 ADA Dental Claim Form.

Anytime a specimen is sent for microscopic examination, it is advisable to hold the claim until a pathology report is received. The pathologist will assign a diagnosis code based on the findings. This code should be reported on the claim as the primary diagnosis. Holding a claim for the pathology report is important, not only because it is the most accurate diagnosis, but also because this diagnosis will be a permanent part of the patient’s clinical record. It is inaccurate to report a lesion as malignant based solely on visual findings. Conversely, if a lesion is reported to an insurance payer as benign, it may be difficult to support the necessity of additional treatment if the pathology report indicates malignancy.

There may be times, however, when the provider determines a lesion is benign and no pathology examination is required. Even when no pathology report is available, medical payers will still require a diagnosis code. Diagnoses codes that may be reported include, but are not limited to:

D10.0 Benign neoplasm of lip

D10.1 Benign neoplasm of tongue

D10.2 Benign neoplasm of floor of mouth

K09.0 Developmental odontogenic cysts

K09.1 Developmental (nonodontogenic) cysts of oral region

K13.0 Diseases of lips (e.g., mucocele)

The diagnoses codes provided above are ICD-10-CM codes. These codes are valid for dates of service on or after October 1, 2015. For additional information on reporting diagnoses codes, refer to the article “ICD-10:It’s Here!” from the September/October 2015 issue of Insurance Solutions Newsletter.

Diagnostic Coding for Dental Claims Submission is also a resource for assistance in reporting diagnoses codes. This guide can be purchased in our Store.