Overview of CPT Code 21615: Excision of benign skin lesion, face, ears, scalp, neck, hands, feet, and genitalia; excised diameter over 4.0 cm.

Overview of CPT Code 21615: Excision of benign skin lesion, face, ears, scalp, neck, hands, feet, and genitalia; excised diameter over 4.0 cm.

CPT Code 21615 refers to the surgical excision of a benign skin lesion located on the face, ears, scalp, neck, hands, feet, or genitalia, where the excised diameter exceeds 4.0 cm. This procedure is typically performed to remove lesions that may be symptomatic, cosmetically concerning, or have the potential for malignancy.

When CPT Code 21615 is Used?

This code is applicable in various clinical scenarios.

• Large benign skin lesions causing discomfort or irritation.
• Lesions that are cosmetically unappealing to the patient.
• Suspicious lesions that require histological examination.
• Lesions that have shown signs of growth or change.

Symptoms Indicating This Procedure

Patients may report various symptoms that necessitate this procedure.

• Visible growth on the skin that is larger than 4.0 cm.
• Itching or irritation at the site of the lesion.
• Bleeding or oozing from the lesion.
• Changes in color or texture of 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

Several diagnostic tests may be conducted prior to the excision.

• Physical examination of the lesion.
• Dermatoscopy to assess the lesion's characteristics.
• Biopsy 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 excised tissue is sent for pathological examination.
• The wound is closed with sutures or adhesive strips.

Preparation for the Procedure

Proper preparation is essential for a smooth procedure.

• Avoid blood thinners like aspirin a week before the procedure.
• Inform the doctor about any allergies or medications.
• Arrive with clean skin, free of lotions or creams.

Recovery and Aftercare

Post-procedure care 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.
• Take prescribed pain medications as needed.

Possible Complications

While complications are rare, they can occur.

• Infection at the excision site.
• Excessive bleeding during or after the procedure.
• Scarring or changes in skin pigmentation.
• Recurrence of the lesion.

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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 the lesion was sent for analysis.

Alternative Treatments

There are non-surgical options available.

• Cryotherapy for smaller lesions.
• Topical treatments for superficial skin lesions.
• Laser therapy for cosmetic concerns.

Home Care Tips

Simple tips can aid in recovery.

• Keep the wound clean and dry.
• Avoid picking at scabs or sutures.
• Use sunscreen on the area once healed.

Patient Education & Prevention

Education is key to preventing future lesions.

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

Billing and Coding Information

CPT Code: 21615

Category: Surgical Procedures

Common Modifiers:

• -50
• -59
• -76

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $500 to $2,000.
• Insurance may cover the procedure if deemed medically necessary.
• Check with your insurance provider for specific coverage details.

Related CPT Codes

• 21616 - Excision, benign lesion, neck
• 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