Overview of CPT Code 21825: Excision of benign skin lesion, face, ears, scalp, neck

CPT Code 21825 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 21825 is Used?

This code is applicable in various clinical scenarios, including:

Removal of benign moles or nevi that are cosmetically unappealing.
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 the following 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 skin lesions.
Itching or tenderness associated with the lesion.

Causes and Risk Factors

Several factors can contribute to the development of benign skin lesions, including:

Genetic predisposition to skin lesions.
Sun exposure leading to skin changes.
Age-related skin changes resulting in benign growths.
Hormonal changes that may influence skin lesions.

Diagnostic Tests Before Procedure

Prior to the excision, the following diagnostic tests may be performed:

Physical examination of the lesion by a healthcare provider.
Dermatoscopy to assess the characteristics of the lesion.
Biopsy may be performed if there is uncertainty about the nature of the lesion.

Procedure Description

The excision procedure typically follows these steps:

Patient is positioned comfortably and the area is cleaned.
Local anesthesia is administered to numb the area.
A surgical incision is made around the lesion.
The lesion is carefully excised along with a margin of healthy tissue.
The incision is closed with sutures or adhesive strips.
Post-operative care instructions are provided.

Preparation for the Procedure

Patients should follow these preparation steps before the procedure:

Avoid blood-thinning medications such as aspirin or ibuprofen for a few days prior.
Inform the healthcare provider of any allergies or medical conditions.
Arrive at the appointment with clean skin and avoid applying makeup.

Recovery and Aftercare

Post-procedure recovery typically involves:

Keeping the surgical site clean and dry.
Changing dressings as instructed by the healthcare provider.
Taking prescribed pain medications as needed.
Avoiding strenuous activities for a few days.

Possible Complications

While generally safe, the procedure may have some risks, including:

Infection at the surgical site.
Scarring or changes in skin pigmentation.
Bleeding or hematoma formation.
Recurrence of the lesion.

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Post-Procedure Follow-Up

Follow-up care is essential for monitoring recovery:

A follow-up appointment is typically scheduled within 1-2 weeks.
Sutures may be removed during the follow-up visit.
Patients should report any signs of infection or unusual symptoms.

Alternative Treatments

For some patients, non-surgical options may be considered, including:

Cryotherapy to freeze off benign lesions.
Topical treatments for superficial skin lesions.
Laser therapy for cosmetic concerns.

Home Care Tips

Patients can follow these tips for effective home care:

Keep the area clean and avoid touching it unnecessarily.
Apply any prescribed ointments as directed.
Monitor for signs of infection, such as increased redness or swelling.

Patient Education & Prevention

To prevent recurrence and promote skin health, consider the following:

Regular skin checks for new or changing lesions.
Use sunscreen to protect skin from UV damage.
Maintain a healthy lifestyle to support skin health.

Billing and Coding Information

CPT Code: 21825

Category: Surgical Procedures

Common Modifiers:

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

Average Cost and Insurance Coverage

The cost of the procedure can vary widely based on several factors:

Average cost ranges from $200 to $1,500 depending on complexity.
Most insurance plans cover excision of benign lesions if deemed medically necessary.
Patients should verify coverage with their insurance provider.