Biopsy of Lip

Question:

A provider performed a shave biopsy of the vermillion border using a dermablade. Would you report 11102 or 40490 for cases like this? What warrants reporting CPT Code 40490?

Answer:

Thank you for your question. For a shave biopsy of the lip skin or vermillion border performed with a dermablade, 11102 is the correct code. CPT 11102 covers tangential (shave/scoop/curette) biopsies of skin and skin appendages, which includes the cutaneous lip and vermillion. A dermablade is the classic instrument for a tangential/shave technique, which maps directly to the 11102 description. The lip, for integumentary coding purposes, is treated as a skin site when the biopsy involves the surface epithelium/vermillion using a shave technique

In order to report CPT code 40490 (biopsy of lip), the biopsy requires incisional technique into the deeper lip tissue (submucosa, muscle). The lesion is on the mucosal surface of the lip (wet mucosa, not vermillion or skin). A punch or excisional approach is used on the lip mucosa and the clinical intent is to sample submucosal pathology (e.g., suspected mucocele, minor salivary gland lesion, deeper fibrosis).

*This response is based on the best information available as of 06/04/26.