Overview of CPT Code 21356: Excision of benign skin lesion, face

Overview of CPT Code 21356: Excision of benign skin lesion, face

CPT Code 21356 refers to the surgical excision of a benign skin lesion located on the face. This procedure is performed to remove non-cancerous growths that may cause cosmetic concerns or discomfort.

When CPT Code 21356 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 decision for excision.

• Visible growth on the face that is bothersome.
• Itching or irritation at the site of the lesion.
• Changes in color or size of the lesion.
• Bleeding or oozing from the lesion.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention.

• Genetic predisposition to skin lesions.
• 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 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

Proper preparation is essential for a smooth procedure.

• Avoid blood thinners like aspirin a week prior.
• Discuss any allergies with your healthcare provider.
• Arrive with a clean face, free of makeup or creams.
• Have a responsible adult accompany you for post-procedure care.

Recovery and Aftercare

Post-procedure care is crucial for healing.

• Expect some swelling and tenderness at the site.
• Keep the area clean and dry for the first few days.
• Follow-up for suture removal as advised by the surgeon.
• Use prescribed pain relief medications as needed.

Possible Complications

While complications are rare, they can occur.

• Infection at the excision site.
• Scarring or changes in skin texture.
• Bleeding during or after the procedure.
• Allergic reaction to anesthesia.

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Post-Procedure Follow-Up

Follow-up is important to ensure proper healing.

• Schedule a follow-up appointment within a week.
• Monitor the site for signs of infection.
• Discuss pathology results if a biopsy was performed.
• Review any concerns regarding healing or appearance.

Alternative Treatments

There are non-surgical options for managing benign lesions.

• Cryotherapy to freeze the lesion.
• Laser therapy for cosmetic improvement.
• Topical treatments for certain types of lesions.

Home Care Tips

Simple home care can aid in recovery.

• Avoid sun exposure on the healing site.
• Do not pick at scabs or sutures.
• Apply any prescribed ointments as directed.
• Keep the area moisturized to promote healing.

Patient Education & Prevention

Education can help prevent future lesions.

• Use sunscreen to protect skin from UV damage.
• Regular skin checks for new or changing lesions.
• Maintain a healthy skin care routine.
• Consult a dermatologist for persistent skin issues.

Billing and Coding Information

CPT Code: 21356

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.
• Insurance may cover the procedure if deemed medically necessary.
• Out-of-pocket costs depend on the insurance plan.

Related CPT Codes

• 21355 - Excision of benign skin lesion, face, ears, scalp
• 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