April 11, 2019
I had a patient that came in for Mohs surgery for a BCC and I noticed another suspicious site on the patient’s scalp. I did a tangential biopsy and pathology, which turned out to be an AK. Can I bill for both the biopsy and pathology that I did of the separate lesion, or only one or the other? I know they are bundled in the coding edits and I am not sure what to do.
Since the biopsy and pathology specific to the new, suspicious lesion was separate from the Mohs procedure you performed on a different lesion (the BCC), both are separately reportable. You will need to append modifier 59 or XS to the codes, depending on what the payor requests.
*This response is based on the best information available as of 4/11/19.