Overview of CPT Code 21355: Excision of benign skin lesion, face, ears, scalp

Overview of CPT Code 21355: Excision of benign skin lesion, face, ears, scalp

CPT Code 21355 refers to the surgical excision of a benign skin lesion located on the face, ears, or scalp. This procedure is performed to remove non-cancerous growths that may cause cosmetic concerns or discomfort.

When CPT Code 21355 is Used?

This code is applicable in various clinical scenarios.

• Presence of a benign skin lesion causing cosmetic concerns.
• Lesions that are symptomatic, such as itching or irritation.
• Lesions that have changed in appearance or size.
• Patient request for removal of a benign lesion for aesthetic reasons.

Symptoms Indicating This Procedure

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

• Visible growth on the skin that is changing in size or color.
• Itching or irritation at the site of the lesion.
• Bleeding or oozing from the lesion.
• Discomfort or pain associated with the lesion.

Causes and Risk Factors

Several factors can contribute to the development of benign skin lesions.

• Genetic predisposition to skin growths.
• Sun exposure leading to skin changes.
• Hormonal changes affecting skin health.
• Previous skin injuries or infections.

Diagnostic Tests Before Procedure

Certain tests may be conducted to confirm the diagnosis before excision.

• Physical examination of the lesion.
• Dermatoscopy to assess the lesion's characteristics.
• Biopsy if there is uncertainty about the nature of the lesion.

Procedure Description

The excision procedure follows a systematic approach.

• Patient is positioned comfortably and the area is cleaned.
• Local anesthesia is administered to numb the area.
• The surgeon excises the lesion along with a margin of healthy tissue.
• The wound is closed with sutures or adhesive strips.
• Dressing is applied to protect the site.

Preparation for the Procedure

Patients should follow specific guidelines to prepare for the excision.

• Avoid blood thinners and certain medications as advised by the physician.
• Do not apply any creams or lotions to the lesion area before the procedure.
• Arrive at the appointment with a clean face and scalp.

Recovery and Aftercare

Post-procedure care is crucial for optimal healing.

• Keep the area clean and dry for the first few days.
• Change the dressing as instructed by the healthcare provider.
• Avoid strenuous activities that may stress the wound.
• Follow up for suture removal if applicable.

Possible Complications

While generally safe, there are potential risks associated with the procedure.

• Infection at the excision site.
• Scarring or changes in skin pigmentation.
• Delayed healing of the wound.
• Recurrence of the lesion.

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Post-Procedure Follow-Up

Regular follow-up is essential to monitor healing.

• Initial follow-up within one week to check the wound.
• Further follow-ups as needed based on healing progress.
• Monitoring for any signs of recurrence or complications.

Alternative Treatments

There are non-surgical options for managing benign skin lesions.

• Topical treatments for superficial lesions.
• Cryotherapy to freeze off the lesion.
• Laser therapy for cosmetic removal.

Home Care Tips

Patients can take simple steps to aid recovery at home.

• Keep the excision site clean and dry.
• Avoid picking at scabs or the wound.
• Use over-the-counter pain relief as needed.

Patient Education & Prevention

Educating patients on skin health can help prevent future lesions.

• Regular skin checks for new or changing lesions.
• Use sunscreen to protect skin from UV damage.
• Maintain a healthy lifestyle to support skin health.

Billing and Coding Information

CPT Code: 21355

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• 59 - Distinct procedural service

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $200 to $1,000 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.
• Out-of-pocket costs may apply based on the insurance plan.

Related CPT Codes

• 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.
• 11406 - Excision, benign skin lesion; face, ears, scalp, neck, excised diameter over 4.0 cm

References and Sources

• American Academy of Dermatology
• Mayo Clinic - Skin Lesions
• Cleveland Clinic - Skin Lesions