ASC Codes for excsion - I bill at an Ambulatory Surgery Center

[dianeeo52]

I bill at an Ambulatory Surgery Center. Physician coded diagnosed codes 216.4 (benign neoplasm of scalp and skin of neck), 238.2 (neoplasm os uncertain behavior of skin), 782.0 (disturbance of skin sensation), and 702.0 (actinic keratosis), in that order, for proceudre codes 13132 and 21555-59. Our off site professional coder simply used 701.1 (keratomderma, acquired) which is actually supported by the path report. The pathology report states the tissue is Lichenoid actinic keratosis. Now the insurance company is investigation whether the surgery was cosmetic. If the physician excises a lesion of uncertain behavior, and it turns out to be a benign keratosis. Can this somehow be resolved by submitting a corrected claim, or is the coder dorrect in only using the diagnosis on the op report. "Uncertain behavior" certainly indicates the need for excision even if it turns out to be benign. Must I file an appeal on this, or a correction? Sorry for length but any inout would be appreciated. Thanks!

dianeeo52:

 

[elenax]

I agree with the off site coder...I would appeal it and if possible have the doctor dictate an addendum indicating the medical necessity for the excision...

 

[mitchellde]

I bill at an Ambulatory Surgery Center. Physician coded diagnosed codes 216.4 (benign neoplasm of scalp and skin of neck), 238.2 (neoplasm os uncertain behavior of skin), 782.0 (disturbance of skin sensation), and 702.0 (actinic keratosis), in that order, for proceudre codes 13132 and 21555-59. Our off site professional coder simply used 701.1 (keratomderma, acquired) which is actually supported by the path report. The pathology report states the tissue is Lichenoid actinic keratosis. Now the insurance company is investigation whether the surgery was cosmetic. If the physician excises a lesion of uncertain behavior, and it turns out to be a benign keratosis. Can this somehow be resolved by submitting a corrected claim, or is the coder dorrect in only using the diagnosis on the op report. "Uncertain behavior" certainly indicates the need for excision even if it turns out to be benign. Must I file an appeal on this, or a correction? Sorry for length but any inout would be appreciated. Thanks!

dianeeo52:

Uncertain behavior dx codes are not be used just because the physician does not know the final pathology prior to excision, The dx of uncertain behavior comes from the path report it is a dx that indicates the cellular activity is of uncertain behavior. It is not supported by the documentation in this case as the path report states actinic keratosis. Excisions are to be coded from the path report. A better way to code this that shows it was not cosmetic is to wait for the path report and when it shows a benign dx then use V71.1 as the first listed dx and the AK as the secondary.