Overview of CPT Code 23395: Excision of benign skin lesion

CPT Code 23395 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 23395 is Used?

This code is applicable in various clinical scenarios.

Removal of a benign skin lesion that is symptomatic or causing discomfort.
Lesions that are growing or changing in appearance.
Lesions that are cosmetically unappealing to the patient.
Suspicion of a benign lesion that requires histological examination.

Symptoms Indicating This Procedure

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

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 and early detection.

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 diagnosis before 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 involves several key steps.

Patient is positioned comfortably and the area is cleaned.
Local anesthesia is administered to numb the area.
The surgeon makes an incision around the lesion.
The lesion is carefully excised along with a margin of healthy tissue.
The incision is closed with sutures or adhesive strips.

Preparation for the Procedure

Proper preparation can enhance the success of the procedure.

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 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 incision site.
Follow up for suture removal if applicable.

Possible Complications

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

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

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Post-Procedure Follow-Up

Follow-up is essential to monitor healing and address any concerns.

Schedule a follow-up appointment within 1-2 weeks post-procedure.
Monitor for signs of infection or complications.
Discuss pathology results if the lesion was sent for analysis.

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 cosmetic concerns.

Home Care Tips

Simple home care can aid in recovery.

Keep the incision site clean and dry.
Avoid picking at scabs or the incision.
Use over-the-counter pain relief as needed.

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 excessive sun exposure and tanning beds.

Billing and Coding Information

CPT Code: 23395

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.