AHA Coding Clinic® for HCPCS - 2019 Issue 2; Ask the editor

Tongue biopsies

Patient with right lateral tongue leukoplakia and ulceration presents for treatment. A laryngoscopy with examination of the tracheal area including the hypopharynx and glottis was performed and no additional lesions were noted. The previous biopsy site was identified and marked. The CO2 laser, on continuous mode at 20 watts was utilized to ablate the right lateral tongue and floor of the mouth in two applications. Small incisional biopsies of the tongue lesion were then performed. The documentation states the specimens removed included incisional biopsies of the right lateral tongue ablated margins. Is the incisional biopsy reported in addition to the laser ablation?  What are the correct codes for all of the procedures performed? What is the correct code for an incisional biopsy that is not performed through the scope? ...

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