Overview of CPT Code 21440: Excision of benign skin lesion, face, ears, scalp

Overview of CPT Code 21440: Excision of benign skin lesion, face, ears, scalp

CPT Code 21440 refers to the surgical excision of benign skin lesions 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 21440 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.
• Lesions that require histological examination to rule out malignancy.

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.
• Pain or discomfort 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 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 malignancy is suspected.

Procedure Description

The excision procedure involves several key steps.

• 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 care instructions are provided.

Preparation for the Procedure

Patients should follow these steps to prepare for the excision.

• Avoid blood thinners like aspirin or ibuprofen a week prior.
• Discuss any allergies with the healthcare provider.
• Arrive with clean skin, free of lotions or makeup.
• Have a responsible adult accompany you if sedation is used.

Recovery and Aftercare

Post-procedure recovery is crucial for healing.

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

Possible Complications

While generally safe, there are potential risks involved.

• Infection at the site of excision.
• 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

Follow-up is essential to monitor healing.

• Schedule a follow-up appointment within 1-2 weeks.
• Remove sutures if applicable during the follow-up.
• Discuss pathology results if a biopsy was performed.
• Monitor for any signs of complications.

Alternative Treatments

There are non-surgical options for managing benign lesions.

• Topical treatments for superficial lesions.
• Cryotherapy to freeze off lesions.
• Laser therapy for certain types of skin growths.

Home Care Tips

Patients can follow these tips for better recovery.

• Keep the excision site clean and dry.
• Avoid picking at scabs or lesions.
• Use sunscreen to protect the healing area.
• Stay hydrated and maintain a healthy diet.

Patient Education & Prevention

Educating patients 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: 21440

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 $1,500.
• Insurance may cover the procedure if deemed medically necessary.
• Out-of-pocket costs depend 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.
• 11420 - 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