Overview of CPT Code 21401: Excision of benign skin lesion, face, ears, scalp, neck

Overview of CPT Code 21401: Excision of benign skin lesion, face, ears, scalp, neck

CPT Code 21401 refers to the surgical excision of benign skin lesions located on the face, ears, scalp, or neck. This procedure is typically performed to remove lesions that are non-cancerous but may cause cosmetic concerns or discomfort.

When CPT Code 21401 is Used?

This code is applicable in various clinical scenarios.

• Presence of benign skin lesions such as moles, cysts, or lipomas that are symptomatic or cosmetically undesirable.
• Lesions that have changed in appearance or size, warranting removal for further evaluation.
• Patient request for removal of benign lesions for aesthetic reasons.

Symptoms Indicating This Procedure

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

• Visible skin lesions that are raised or discolored.
• Itching or irritation associated with the lesion.
• Lesions that bleed or ooze.
• Cosmetic concerns regarding the appearance of the lesion.

Causes and Risk Factors

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

• Genetic predisposition to skin lesions.
• Sun exposure leading to skin changes.
• Hormonal changes that may influence skin growth.
• Previous skin injuries or infections.

Diagnostic Tests Before Procedure

Certain tests may be conducted to ensure the appropriateness of the excision.

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

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.
• Post-operative instructions are provided to the patient.

Preparation for the Procedure

Patients should follow specific guidelines before the procedure.

• Avoid blood thinners such as aspirin or ibuprofen for a week prior.
• Inform the surgeon of any allergies or medical conditions.
• Arrive with clean skin, free of lotions or makeup.

Recovery and Aftercare

Post-procedure care is crucial for optimal healing.

• Keep the surgical site clean and dry.
• Change dressings as instructed by the healthcare provider.
• Avoid strenuous activities for at least a week.
• Follow up for suture removal if applicable.

Possible Complications

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

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

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

Post-Procedure Follow-Up

Monitoring after the procedure is essential.

• Follow-up appointment within 1-2 weeks to assess healing.
• Additional visits if complications arise.
• Regular skin checks for new lesions or changes.

Alternative Treatments

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

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

Home Care Tips

Patients can take steps to aid recovery at home.

• Keep the area clean and avoid touching it.
• Use over-the-counter pain relief as needed.
• Monitor for signs of infection such as increased redness or swelling.

Patient Education & Prevention

Educating patients on skin health is vital.

• Regularly check skin for new or changing lesions.
• Use sunscreen to protect skin from UV damage.
• Consult a dermatologist for any concerns about skin changes.

Billing and Coding Information

CPT Code: 21401

Category: Surgery

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 $1,500 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.
• Patients should verify coverage with their insurance provider.

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.
• 11404 - Excision, benign skin lesion, face, ears, scalp; excised diameter over 4.0 cm.

References and Sources

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