Skin Biopsies and Lesion Removal: Biopsy vs. Shave vs. Excision
The everyday dermatology procedures — biopsy, shave, and excision — are distinguished by documented intent and technique, and mixing them up is the most common coding error.
Biopsy: a technique hierarchy
- 11102 / +11103 — tangential (shave/scoop) biopsy, first lesion / each additional
- 11104 / +11105 — punch biopsy, first / each additional
- 11106 / +11107 — incisional biopsy, first / each additional
Report one primary biopsy code per session — the highest in the hierarchy performed — then add-ons for each additional lesion biopsied, regardless of technique mix. A biopsy is sampling for diagnosis, not complete removal.
Shave vs. excision
Shave removal (11300–11313) is complete removal by transverse technique, coded by site and lesion diameter. Excision is full-thickness removal, coded benign (11400–11446) or malignant (11600–11646) by site and by excised diameter including margins — document the margin measurement. Simple closure is included in excision; intermediate/complex repairs are separate.
Same-day rule
A biopsy of the same lesion on the same day as its definitive excision or Mohs is generally not separately reportable.
Clinical Capture reads the documented technique and intent, applies the biopsy hierarchy with add-ons, and separates includable closure from separately-reportable repair.
This article is educational and not coding, billing, or legal advice. Always verify codes and values against the current CPT®, ICD-10-CM, and CMS Physician Fee Schedule, follow NCCI edits and payer policy, and confirm with a certified coder before submitting a claim. Document only work that was actually performed.