Overview of CPT Code 21360: Excision of benign skin lesion, face or scalp

Overview of CPT Code 21360: Excision of benign skin lesion, face or scalp

CPT Code 21360 refers to the surgical excision of a benign skin lesion located on the face or scalp. This procedure is performed to remove non-cancerous growths that may cause cosmetic concerns or discomfort.

When CPT Code 21360 is Used?

This code is applicable in various clinical scenarios.

• Removal of a benign mole that is changing in appearance.
• Excision of a seborrheic keratosis that is irritating or bothersome.
• Surgical intervention for a lipoma located on the scalp.
• Excision of a dermatofibroma that is symptomatic or for cosmetic reasons.

Symptoms Indicating This Procedure

Patients may report several symptoms that warrant this procedure.

• A noticeable growth on the face or scalp.
• Itching or irritation at the site of the lesion.
• Changes in color, size, or shape 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 trauma.
• Certain skin conditions like acne or eczema.

Diagnostic Tests Before Procedure

Certain tests may be conducted to confirm the need for excision.

• Physical examination of the lesion.
• Dermatoscopy to assess the characteristics of the lesion.
• Biopsy if malignancy is suspected.

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.
• A scalpel is used to excise 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 clean skin, free of makeup or lotions.
• Have a responsible adult accompany you post-procedure.

Recovery and Aftercare

Post-procedure care is crucial for healing.

• Keep the area clean and dry for the first few days.
• Change the dressing as instructed by your doctor.
• Avoid strenuous activities for at least a week.
• Watch for signs of infection such as increased redness or pus.

Possible Complications

While complications are rare, they can occur.

• 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

Follow-up is important to ensure proper healing.

• Schedule a follow-up appointment within 1-2 weeks.
• Monitor the site for any unusual changes.
• Discuss pathology results if a biopsy was performed.

Alternative Treatments

There are non-surgical options available.

• Cryotherapy for superficial lesions.
• Topical treatments for certain benign skin conditions.
• Laser therapy for cosmetic concerns.

Home Care Tips

Simple tips can aid in recovery.

• Keep the wound clean and dry.
• Avoid picking at scabs or sutures.
• Use sunscreen on the area once healed.
• Stay hydrated and maintain a healthy diet.

Patient Education & Prevention

Education can help prevent future lesions.

• Regular skin checks for new or changing lesions.
• Use sunscreen to protect against UV damage.
• Avoid tanning beds and excessive sun exposure.
• Consult a dermatologist for any skin concerns.

Billing and Coding Information

CPT Code: 21360

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.
• Check with your insurance provider for specific coverage details.

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