• Billing Diagnosis for Biopsies


    I often see eyelid lesions that I know are benign; however, I do not always know the precise name a pathologist would give the lesion.  To be safe, I send it for confirmatory histopathology.  
    What is the best practice here, do I have to bill it as a biopsy even when I know the lesion is benign? Do I code it as benign removal and pair it with the best clinical diagnosis? Or do I wait for the pathology report to return and finish my note and my billing once I have the final path? 

    Answer: Best practice is to wait for the pathology report and then you can submit the corresponding, confirmed diagnosis.
    Additional instruction on correct coding for skin biopsies can be found in Fundamentals of Ophthalmic Coding and the Oculofacial Coding Assistant.