11100 vs 11401

[june616]

The provider removed a skin lesion and the claim was billed to Humana with dx239.2 and 11401 procedure code. Humana denied as diagnosis not consistent procedure. I checked the path report and determined that the dx should be changed to 238.2. It is appropriate to still code 11401 with this diagnosis? The provider performed a full thickness punch and a simple suture closure. I know that typically 238.2 is billed with 11100. Thanks for your help.

[CODE.REBECCA.DEWICK]

we try to rarely use excision codes with "unknown" neoplasms due to excisions being specified as malignant or benign and which do you choose if it is truly "unknown". When it is a true excision we note if it is dysplastic/atypical and put that on the claim... dysplastic skin dx is 709.8

so 11100 = 238.2

or

11401 = 238.2
709.8
you mentioned a path report, if the path report was obtained from the procedure then i would use 11100, it path was already received and it is a re-excision then i would report the 11401 with the extra dx of dysplastic skin...

[grth97]

You need to bill what the provider stated in the notes. If they stated punch biopsy then you should code 11100. If they stated punch excision then 114**. If they did not mention then you need to query them. 238.2 is used when the path comes back as uncertain behavior. If the provider performed a biopsy and the path comes back as uncertain behavior the provider might want the patient to come back for excision. If you have already changed the biopsy on the first visit to excision the insurance will question why double excision.

[peachygirl]

Hello,
I agree with above coders, 238.2 is the general "uncertain" diagnosis but it does also describe keratoacanthoma, per ICD-9. If the path came back with KA then you could just use the 238.2, but as per above notes if it is anything else you need the specific dx which is generally a 216.X code for benign skin lesions.

Hope that helps!

Mallory, CPC, CPCD