Overview of CPT Code 21602: Excision of benign skin lesion, face, ears, scalp, neck

Overview of CPT Code 21602: Excision of benign skin lesion, face, ears, scalp, neck

CPT Code 21602 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 21602 is Used?

This code is applicable in various clinical scenarios.

• Removal of benign moles or nevi that are cosmetically undesirable.
• Excision of seborrheic keratosis that may be irritated or inflamed.
• Surgical intervention for lipomas located on the face or neck.
• Excision of dermatofibromas that are symptomatic or bothersome.

Symptoms Indicating This Procedure

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

• Visible skin lesions that are growing or changing in appearance.
• Lesions that cause discomfort or irritation.
• Cosmetic concerns regarding the appearance of facial or neck lesions.
• Itching or tenderness associated with the lesion.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention and early detection.

• Genetic predisposition to skin lesions.
• Sun exposure leading to skin changes.
• Age-related skin changes resulting in benign lesions.
• History of skin trauma or irritation.

Diagnostic Tests Before Procedure

Certain tests may be conducted to confirm the diagnosis before excision.

• Physical examination of the lesion by a dermatologist.
• Dermatoscopy to evaluate the characteristics of the lesion.
• Biopsy may be performed 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 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.
• Arrange for transportation if sedation is used.

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 a few days.
• Monitor for signs of infection such as increased redness or discharge.

Possible Complications

While complications are rare, they can occur.

• Infection at the surgical 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 appointments are essential for monitoring recovery.

• Initial follow-up within 1-2 weeks to check the surgical site.
• Suture removal if applicable, typically within 7-14 days.
• Further follow-up as needed based on healing and pathology results.

Alternative Treatments

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

• Cryotherapy for superficial lesions.
• Topical treatments for certain skin conditions.
• Laser therapy for cosmetic improvement of skin lesions.

Home Care Tips

Simple home care can aid in recovery.

• Keep the area clean and avoid touching it.
• Use over-the-counter pain relief as needed.
• Apply ice packs to reduce swelling if necessary.
• Follow all post-operative care instructions provided.

Patient Education & Prevention

Educating patients can help prevent future lesions.

• Regular skin checks for new or changing lesions.
• Use sunscreen to protect skin from UV damage.
• Avoid excessive sun exposure, especially during peak hours.
• Maintain a healthy skin care routine.

Billing and Coding Information

CPT Code: 21602

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 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.
• Out-of-pocket costs may apply based on individual insurance plans.

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