May 11, 2017

Question:
My physician documents a biopsy via “shave technique”. Is this the correct way to document a biopsy and report the procedure with 11100?

Answer:
Payors discourage physicians from documenting in the record a “shave biopsy” or “shave technique” which is many time confused with a shave excision. When reporting and documenting a biopsy it is important to document the site of the biopsy and avoid the term “shave”.

CPT 11100 is reported for the first biopsy and 11101 is reported for each additional lesion biopsied.

When the term shave biopsy or shave technique is documented is should be reported as a shave excision using CPT category 11300-11313. Code selection is dependent on the location (site) and size of the lesion shaved..

*This response is based on the best information available as of 05/11/17.