Overview of CPT Code 21116: Excision of benign lesion, face, ears, scalp, neck

Overview of CPT Code 21116: Excision of benign lesion, face, ears, scalp, neck

CPT Code 21116 refers to the surgical excision of a benign lesion located on the face, ears, scalp, or neck. This procedure is typically performed to remove non-cancerous growths that may cause cosmetic concerns or discomfort.

When CPT Code 21116 is Used?

This code is applicable in various clinical scenarios.

• Presence of a benign tumor or cyst causing discomfort or cosmetic issues.
• Lesions that are growing or changing in appearance.
• Skin tags or other benign lesions that patients wish to have removed for aesthetic reasons.
• Lesions that may be causing irritation or friction.

Symptoms Indicating This Procedure

Patients may report several symptoms that lead to the consideration of this procedure.

• Visible growths on the skin that are changing in size or color.
• Pain or discomfort associated with the lesion.
• Itching or irritation in the area of the lesion.
• Bleeding or oozing from the lesion.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention and early detection.

• Genetic predisposition to skin growths.
• Sun exposure leading to skin changes.
• Previous skin injuries or infections.
• Certain skin conditions like seborrheic keratosis.

Diagnostic Tests Before Procedure

Before the excision, certain diagnostic tests may be performed.

• Physical examination of the lesion.
• Dermatoscopy to assess the characteristics of the lesion.
• Biopsy if there is any suspicion of malignancy.

Procedure Description

The excision procedure involves several key steps.

• Patient is positioned comfortably and the area is cleaned.
• Local anesthesia is administered to numb the area.
• The surgeon makes an incision around the lesion.
• The lesion is carefully excised along with a margin of healthy tissue.
• The incision is closed with sutures or adhesive strips.

Preparation for the Procedure

Proper preparation can enhance the success of the procedure.

• Avoid blood thinners and certain medications as advised by the physician.
• Do not eat or drink for a specified period before the procedure if sedation is planned.
• Arrive at the facility with clean skin and avoid applying lotions or makeup.

Recovery and Aftercare

Post-procedure care is crucial for optimal healing.

• Expect some swelling and discomfort for a few days.
• Keep the area clean and dry; follow wound care instructions.
• Avoid strenuous activities for at least a week.
• Take prescribed pain medications as needed.

Possible Complications

While complications are rare, they can occur.

• Infection at the site of excision.
• Scarring or changes in skin pigmentation.
• Recurrence of the lesion.
• Allergic reactions to anesthesia.

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Post-Procedure Follow-Up

Follow-up is essential to monitor healing.

• Schedule a follow-up appointment within 1-2 weeks post-procedure.
• Monitor for signs of infection or complications.
• Discuss pathology results if a biopsy was performed.

Alternative Treatments

There are non-surgical options available for benign lesions.

• Cryotherapy to freeze off the lesion.
• Laser therapy for superficial lesions.
• Topical treatments for certain skin conditions.

Home Care Tips

Simple home care can aid in recovery.

• Keep the surgical site clean and dry.
• Apply any prescribed ointments as directed.
• Avoid picking at the scab or incision site.

Patient Education & Prevention

Educating patients can help prevent future lesions.

• Regular skin checks for new or changing lesions.
• Use sunscreen to protect skin from UV damage.
• Avoid excessive sun exposure and wear protective clothing.

Billing and Coding Information

CPT Code: 21116

Category: Surgery

Common Modifiers:

• 50 - Bilateral procedure
• RT - Right side
• LT - Left side

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $200 to $1,500 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.
• Check with your insurance provider for specific coverage details.

Related CPT Codes

• 11100 - Biopsy of skin, single lesion
• 11400 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11401 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11402 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11403 - Excision, benign skin lesion, face, ears, scalp; excised diameter over 4.0 cm.

References and Sources

• American Academy of Dermatology
• Mayo Clinic - Skin Lesions