What should a billing and coding specialist verify if the procedure notes indicate an incisional biopsy but the lesion was completely removed?

In situations where the procedure notes indicate an incisional biopsy but the lesion was completely removed, the most crucial verification is to ensure that an excisional procedure was actually performed. This is important because the coding for the procedure must accurately reflect what was done during the medical intervention.

The distinction between an incisional biopsy and an excisional biopsy is significant for proper coding and billing. An incisional biopsy typically involves removing a portion of the lesion for diagnostic purposes, whereas an excisional biopsy means the entire lesion has been removed and is often performed with the intention of treatment. If the provider intended for an excisional biopsy but documented it as an incisional biopsy, it may affect the reimbursement and future patient care.

Correctly identifying and coding for the performed procedure ensures compliance with coding standards and represents the true nature of the patient care provided. This verification supports accurate medical records, appropriate billing, and optimal patient management moving forward.