Ophthalmology and Optometry Coding Alert

Question: What diagnosis code should I use when the physician removes a lesion and does not send it to the lab? I report code 373.9 (Unspecified inflammation of eyelid); 374.84 (Cysts of eyelids) for my Medicare carrier, and they deny it. North Carolina Subscriber Answer: Many state Medicare carriers limit removal of benign skin lesions because this is often a cosmetic procedure. According to the LMRP issued by Noridian, a Part B Medicare carrier for several Western states, benign skin lesions are common in the elderly, and lesions that do not pose a threat to health or function are considered cosmetic and are not covered. A lesion should exhibit certain signs before removal, if it is to be considered noncosmetic:
The lesion has one or more of certain characteristics, including bleeding, intense itching, and pain
The lesion shows evidence of inflammation
It obstructs an orifice or restricts vision
There is a clinical uncertainty regarding the likely diagnosis
Aprior biopsy suggest malignancy
The lesion is in a region subject to recurrent physical trauma, and documentation shows it has occurred
Wart removal is considered under the above circumstances. Noridian's LMRP lists only five covered ICD-9 codes:
078.10 Viral warts, unspecified
078.19 Other specified viral warts
702.11 Inflamed seborrheic keratosis
702.19 Other seborrheic keratosis
706.20 Sebaceous cyst. You must clearly document in the patient's medical records the medical necessity of the lesion removal. In your scenario, it would be hard to establish medical necessity because the skin lesions were not sent to a laboratory for analysis. The only circumstance following the parameters listed above would be if a prior biopsy proved malignancy or another accepted diagnosis.