Overview of CPT Code 21386: Excision of benign skin lesion, face, ears, scalp

Overview of CPT Code 21386: Excision of benign skin lesion, face, ears, scalp

CPT Code 21386 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 21386 is Used?

This code is applicable in various clinical scenarios.

• Removal of benign moles or nevi that are cosmetically unappealing.
• Excision of seborrheic keratosis that may be irritated or inflamed.
• Surgical intervention for dermatofibromas that cause discomfort.
• Excision of lipomas located on the face or scalp.

Symptoms Indicating This Procedure

Patients may report several symptoms prompting the need for this procedure.

• Visible skin lesions that are growing or changing in appearance.
• Lesions that cause itching, irritation, or discomfort.
• Concerns about the cosmetic appearance of skin lesions.
• Pain or tenderness associated with 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 benign skin growths.
• Age-related changes in skin leading to lesions.
• Previous skin injuries or trauma.

Diagnostic Tests Before Procedure

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

• Physical examination of the lesion by a dermatologist.
• Dermatoscopy to assess the characteristics of the lesion.
• Biopsy may be performed 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 area.

Preparation for the Procedure

Proper preparation is essential for a smooth procedure.

• Avoid blood thinners like aspirin or ibuprofen a week prior.
• Inform the doctor about any allergies or medications.
• Arrive with clean skin and avoid applying lotions or makeup.

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 the healthcare provider.
• Avoid sun exposure on the healing site.
• Pain relief can be managed with over-the-counter medications.

Possible Complications

While complications are rare, they can occur.

• Infection at the excision site.
• Scarring or changes in skin pigmentation.
• Delayed healing or wound dehiscence.
• Allergic reaction to sutures or topical medications.

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Post-Procedure Follow-Up

Follow-up is important to monitor healing.

• Schedule a follow-up appointment within 1-2 weeks.
• Monitor for signs of infection or complications.
• 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 excision site clean and dry.
• Avoid picking at scabs or sutures.
• Use sunscreen to protect the area from UV exposure.

Patient Education & Prevention

Education can help prevent future lesions.

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

Billing and Coding Information

CPT Code: 21386

Category: Surgical Procedures

Common Modifiers:

• -50
• -59
• -76

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