What are Benign Lesions

Benign lesions are contained, ie, they lack the ability to  invade neighboring tissues, or metastasize. Skin lesions that are considered benign include lipomas, cysts, fibromas, nevi, and some moles. The codes in this series are used to report the excision of benign lesions that  originate in the integumentary system. The actual lesion and excision may extend beyond the integumentary  system. A margin of healthy full-thickness skin is usually excised with the benign lesion. The diameter of the entire excision (including margin) is used to calculate the measurement necessary for CPT code selection.

Any repair of the surgical site that requires layered closure, extensive undermining, or retention sutures may be reported separately. When the morphology of a lesion is ambiguous, the coder should choose the excision code  category (malignant vs benign) based on the physician’s approach to the lesion rather than the final pathology  report. In this way, the coding will reflect the physician’s knowledge, skill, time, and effort, regardless of the pathology report. For example, a lesion suspected of being benign would be excised with relatively smaller margins than a lesion suspected of being malignant.

Read also: Coding sample report for skin lesion CPT code

CPT codes for Coding Benign lesion

When the lesion is clearly benign (eg, cyst, lipoma, prior biopsy of benign neoplasm), the excision can be coded as benign at the time of surgery from code series CPT 11400-11471.

What are Malignant Lesion?