Urology Coding Alert

Question: Benign lesion excisions are not covered by our state Medicaid. We have been losing payment as we confirm the benign nature of the lesion only after we get the histopathology report. Can you please suggest how we can ensure we will be reimbursed for a benign lesion excision?

Oregon Subscriber

Answer: Payer policies exclude coverage of benign lesions, as they are considered cosmetic unless it is confirmed and documented as causing the patient pain or irritation necessitating removal. Often for payment of these benign lesions a secondary diagnosis is needed to express medical necessity for lesion removal.

Example: If the primary diagnosis for an excised lesion is a sebaceous cyst (706.2), a secondary diagnosis expressing medical necessity would also be required for payment. These diagnoses may be 459.0 (Hemorrhage, unspecified, 686.8, other specified local infections of skin and subcutaneous tissue), 686.9 (Unspecified local infection of skin and subcutaneous tissue), 695.9 (Unspecified erythematous condition), and 782.0 (Disturbance of skin sensation). With the use of both a primary and secondary diagnosis indicating medical necessity, many of these excisional procedures will be paid.

Remember: If a payer still considers the procedure to be cosmetic and denies payment, you may request that the patient preoperatively sign a waiver indicating that he/she may be financially responsible for the full payment of the procedure.