Name of the Procedure

Common Name: Pathology Report for Skin Cancer Biopsy
Technical Term: HCPCS Code G9785 - Pathology Report Diagnosing Cutaneous Basal Cell Carcinoma, Squamous Cell Carcinoma, or Melanoma (Including In Situ Disease)

Summary

A skin sample taken during a biopsy is examined by a pathologist or dermatopathologist to diagnose types of skin cancer such as basal cell carcinoma, squamous cell carcinoma, or melanoma and report the findings back to the clinician within 7 days.

Purpose

Diagnosing skin cancers ensures the precise type and severity of the condition are identified, guiding appropriate treatment. Early and accurate diagnosis is crucial for effective management and improved patient outcomes.

Indications

• Anomalous skin lesions or growths
• Persistent sores that do not heal
• Changes in the size, shape, or color of moles or other skin marks
• Lesions that bleed, itch, or become tender

Preparation

• No special preparation required from the patient
• Prior diagnostic tests may include dermoscopy or a full skin examination

Procedure Description

1. Biopsy Collection: A dermatology clinician collects a sample of the skin lesion using techniques such as shave, punch, or excisional biopsy.
2. Sample Transportation: The skin sample is preserved and sent to a pathology lab.
3. Histopathological Examination: A pathologist examines the tissue under a microscope to identify the presence and type of cancer cells.
4. Diagnosis Report: The pathologist prepares a detailed report, specifying the type of skin cancer and any relevant histological features, which is sent to the biopsying clinician.

Duration

The pathology examination and report preparation take up to 7 days from the time the tissue is received by the lab.

Setting

Pathology laboratories typically located within hospitals or specialized diagnostic centers.

Personnel

• Dermatology Clinician: Performs the biopsy
• Pathologist/Dermatopathologist: Conducts the tissue analysis
• Laboratory Technicians: Assist with sample preparation and processing

Risks and Complications

• Minor risks related to biopsy procedure (e.g., infection, bleeding)
• Misdiagnosis or delayed diagnosis if sample improperly handled or analyzed (rare)

Benefits

• Accurate and timely identification of skin cancer type
• Facilitates treatment planning and potential early intervention
• Enhances prognosis by enabling appropriate therapeutic measures

Recovery

• Post-biopsy, minor wound care is required at the biopsy site.
• Follow-up appointment with the clinician to review pathology results and discuss treatment options.
• Recovery from the biopsy is typically quick with minimal restrictions.

Alternatives

• Clinical observation and follow-up if the lesion appears benign
• Imaging studies for deeper or less accessible lesions
• Direct excision without pathologic confirmation (less common and typically not recommended)

Patient Experience

• The biopsy site might be sore or tender post-procedure.
• Some discomfort or bruising may be experienced.
• Over-the-counter pain medication can be used to manage pain.
• Patients may feel anxious while awaiting results but should be reassured by the clinical team's support and clear communication throughout the process.