John,
For clarification, most of the time I will do a punch biopsy first to make the diagnosis and then excise the lesion, if warranted. The initial question was how to bill the diagnosis code. Sometimes, in the course of the punch biopsy, one will remove the entire lesion and it will turn out to be malignant. Sometimes, based on experience and the appearance, you will know the lesion is malignant and just remove it without a biopsy first. The reason that you get paid more for the definitive surgery is because of the calculated risk based on the diagnosis and management, how ever that is figured out. It must have had something to do with the initial RVU that the surgeons came up with. As we see with other parts of medicine, procedures pay more than our critical thinking skills. In this day and age, with the cost of our overhead, any procedures we can do in the office, presuming that we are independent and not employed, add to the bottom line. If I was trying to make it on just doing office visits and an occasional EKG, it would be difficult. The difference in RVUs is amazing. You can get paid more to remove a cerumen impaction from a Medicare patient's ear canals than you can to manage their diabetes, hyperlipidemia and hypertension and write all the prescripitons at the visit.
