Overview of CPT Code 21936: Excision of benign skin lesion

CPT Code 21936 refers to the surgical excision of a benign skin lesion, which is a non-cancerous growth on the skin. This procedure is performed to remove lesions that may cause discomfort, cosmetic concerns, or have the potential for changes that could lead to malignancy.

When CPT Code 21936 is Used?

This code is applicable in various clinical scenarios.

Removal of a benign skin tumor that is symptomatic or bothersome to the patient.
Excision of a lesion that has changed in appearance or size.
Lesions that are suspected to be precursors to skin cancer.
Cosmetic removal of lesions for aesthetic reasons.

Symptoms Indicating This Procedure

Patients may report various symptoms that lead to the decision for excision.

Itching or irritation at the site of the lesion.
Bleeding or oozing from the lesion.
Changes in color, size, or shape of 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 or dermatofibromas.

Diagnostic Tests Before Procedure

Certain tests may be conducted to confirm the need for excision.

Physical examination of the lesion.
Dermatoscopy to assess the lesion's characteristics.
Biopsy 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.
Dressing is applied to protect the site.

Preparation for the Procedure

Proper preparation can enhance the procedure's success.

Avoid blood thinners and certain medications as advised by the physician.
Inform the doctor about any allergies or medical conditions.
Arrive with clean skin and avoid applying lotions or creams on the day of the procedure.

Recovery and Aftercare

Post-procedure care is crucial for healing.

Keep the area clean and dry for the first few days.
Change the dressing as instructed by the healthcare provider.
Avoid strenuous activities that may stress the wound.
Follow up for suture removal if applicable.

Possible Complications

While generally safe, there are potential risks.

Infection at the excision site.
Scarring or changes in skin pigmentation.
Recurrence of the lesion.
Delayed healing.

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Post-Procedure Follow-Up

Regular follow-up is important for monitoring recovery.

Initial follow-up within 1-2 weeks to check healing.
Further follow-ups as needed based on the lesion type and healing progress.
Monitoring for any signs of recurrence.

Alternative Treatments

There are non-surgical options available.

Cryotherapy to freeze off the lesion.
Laser therapy for superficial lesions.
Topical treatments for certain benign skin conditions.

Home Care Tips

Simple tips can aid in recovery.

Keep the excision site clean and dry.
Avoid picking at scabs or the wound.
Use over-the-counter pain relief as needed.
Monitor for signs of infection such as increased redness or swelling.

Patient Education & Prevention

Education 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: 21936

Category: Surgical Procedures

Common Modifiers:

25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure.
59 - Distinct procedural service.