One-liner#

Office skin biopsy for diagnosis (shave/punch/incisional) when malignancy or specific derm diagnosis is on the differential.

Don’t miss / refer#

• High suspicion melanoma or complex lesion in cosmetically sensitive area (consider derm referral if not comfortable)
• Bleeding disorders/anticoagulation concerns (individualize)

Minimum documentation#

• Clinical description: size, location, appearance, and differential
• Biopsy type (shave/punch/incisional), tool size (e.g., punch diameter)
• Consent and risks (bleeding, infection, scar, incomplete diagnosis)
• Local anesthesia (agent and amount)
• Hemostasis method
• Specimen labeling and what was sent to pathology
• Aftercare instructions and result follow-up plan

Coding + RVU table scaffold#

Codes depend on technique and anatomic site; pick the correct family and confirm payer rules.