Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion
CPT4 code
Name of the Procedure:
Biopsy of skin, subcutaneous tissue, and/or mucous membrane (including simple closure) for a single lesion.
Summary
A skin biopsy involves taking a small sample of skin, subcutaneous tissue, or mucous membrane for examination under a microscope. This helps diagnose various skin conditions, infections, or skin cancers.
Purpose
The procedure is conducted to diagnose skin disorders, infections, and cancers. By examining the tissue sample, doctors can determine the cause of abnormal skin changes and plan appropriate treatment.
Indications
- Unexplained skin lesions
- Changes in moles or birthmarks
- Persistent rashes or infections
- Suspected skin cancers
- Chronic skin conditions that do not respond to treatment
Preparation
- Clean the biopsy site
- Inform the doctor of any allergies or medications
- No fasting is typically required
- Some conditions may require blood tests or allergy screenings beforehand
Procedure Description
- The area around the lesion is cleaned and disinfected.
- Local anesthesia is injected to numb the area.
- A small sample of skin, subcutaneous tissue, or mucous membrane is removed using a scalpel or biopsy punch.
- The sample is placed in a container for laboratory examination.
- The biopsy site is closed with stitches if necessary, and dressed with a bandage.
Duration
Typically, the procedure takes about 15-30 minutes.
Setting
The procedure is usually performed in an outpatient clinic or a dermatologist's office.
Personnel
- Dermatologist or surgical specialist
- Nurse or medical assistant
- Pathologist (who examines the biopsy sample)
Risks and Complications
- Infection at the biopsy site
- Bleeding or bruising
- Scarring
- Allergic reaction to local anesthesia
- Rarely, incorrect diagnosis or need for additional biopsies
Benefits
- Accurate diagnosis of skin conditions
- Early detection and treatment of skin cancers
- Guidance for effective treatment options
- Results are usually available within a few days to a week
Recovery
- Keep the biopsy site clean and dry
- Follow any wound care instructions provided by your doctor
- Minor discomfort or pain can be managed with over-the-counter pain relievers
- Avoid strenuous activities that might stress the biopsy site for a few days
- Follow-up appointment may be required to discuss results
Alternatives
- Clinical examination without biopsy, though not as definitive
- Imaging studies, which are less invasive but less diagnostic
- Watchful waiting for changes in the lesion, which may delay diagnosis
Patient Experience
- The patient may feel a brief sting from the anesthesia injection.
- The area will be numb during the procedure, so there should be minimal discomfort.
- Some soreness at the biopsy site is normal after the procedure, but manageable with pain relief measures.
Pain management includes local anesthesia during the procedure and over-the-counter pain medication as needed afterward.