Overview of CPT Code 21465: Excision of benign skin lesion, face, ears, eyelids, scalp

Overview of CPT Code 21465: Excision of benign skin lesion, face, ears, eyelids, scalp

CPT Code 21465 refers to the surgical excision of benign skin lesions located on the face, ears, eyelids, or scalp. This procedure is performed to remove non-cancerous growths that may cause cosmetic concerns or discomfort.

When CPT Code 21465 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 lesion for aesthetic reasons.

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.
• Discomfort or pain associated with the lesion.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention.

• Genetic predisposition to skin growths.
• Sun exposure leading to skin changes.
• Previous skin injuries or infections.
• Certain skin conditions, such as seborrheic keratosis.

Diagnostic Tests Before Procedure

Before the excision, certain diagnostic tests may be performed.

• 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 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

Proper preparation can enhance the success of the procedure.

• Avoid blood thinners and certain medications as advised by the physician.
• Arrive with clean skin, free of lotions or makeup.
• Discuss any allergies or medical conditions with the healthcare provider.

Recovery and Aftercare

Post-procedure care is crucial for optimal healing.

• Keep the area clean and dry for the first few days.
• Change dressings as instructed by the healthcare provider.
• Avoid strenuous activities that may stress the wound.
• Monitor for signs of infection, such as increased redness or discharge.

Possible Complications

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

• Infection at the site of excision.
• 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 to assess healing.
• Remove sutures if applicable during the follow-up visit.
• Report any unusual symptoms or concerns to the healthcare provider.

Alternative Treatments

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

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

Home Care Tips

Patients can take steps at home to aid recovery.

• Keep the excision site clean and dry.
• Avoid picking at scabs or the wound.
• Use sunscreen to protect the healing area from sun exposure.

Patient Education & Prevention

Educating patients can help prevent future lesions.

• Regular skin checks for new or changing lesions.
• Use of sunscreen to protect against UV damage.
• Avoiding tanning beds and excessive sun exposure.

Billing and Coding Information

CPT Code: 21465

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• RT - Right side
• LT - Left side

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.
• 11406 - 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
• Cleveland Clinic - Skin Lesions