Wiki 11104 biopsy with diagnosis code R21 Rash.

[Brandy0618]

Does anyone have information or guidance on how our providers can get reimbursed when submitting 11104 with R21? These are rashes in question. Not neoplasms. I am at a loss as when our providers are trying to rule out or prove one rash vs another. Obviously, we cannot use a diagnosis of dermatitis or Tinea versicolor when we do not know what it is yet. The provider is trying to determine that.

Thank you for any help or advice.

 

[thomas7331]

It's been a number of years since I worked in dermatology, but I don't recall ever having a problem getting reimbursed in this situation. Are you finding some insurance companies that won't pay this? If so, what reason are they giving you? If the provider feels that a biopsy is medically necessary for the patient, it should not be denied unless the payer has a written policy that excludes coverage for this, in which case the patient should be responsible.

 

[TThivierge]

Hi Brandy
Umm I can see why the rash was denied. Doing a bx on just a skin rash....provider needs to give clearer documentation select a better dx code. There are so many numerous skin disease descriptions might be more specific. However, at previous hospital worked at we were told if provider cannot be more specific use dx L98.8 as primary dx then R21.
I hope this data help you
Lady T

 

[Brandy0618]

Hi Brandy
Umm I can see why the rash was denied. Doing a bx on just a skin rash....provider needs to give clearer documentation select a better dx code. There are so many numerous skin disease descriptions might be more specific. However, at previous hospital worked at we were told if provider cannot be more specific use dx L98.8 as primary dx then R21.
I hope this data help you
Lady T

Thank you for your help and information. I have also noticed that biopsy codes are not included on the LCD. Does anyone know why?

 

[Brandy0618]

It's been a number of years since I worked in dermatology, but I don't recall ever having a problem getting reimbursed in this situation. Are you finding some insurance companies that won't pay this? If so, what reason are they giving you? If the provider feels that a biopsy is medically necessary for the patient, it should not be denied unless the payer has a written policy that excludes coverage for this, in which case the patient should be responsible.

I was told that this is a recent exclusion. The carrier stated it was not an acceptable diagnosis code. However, when I try and locate the LCD on biopsies, there are not any specific to 11102-11107. If the carrier has included they will not reimburse biopsies if reported with rash, is it acceptable to bill the patient?

 

[TThivierge]

Hi Brandy,

• The treatment for a rash usually depends on its cause. Options include moisturizers, lotions, baths, cortisone creams that relieve swelling, and antihistamines, which relieve itching. Any change in the skin which affects its appearance or texture. A rash may be localized to one part of the body, or affect all the skin.
• Reference https://www.aafp.org/pubs/afp/issues/2010/0315/p726.html Family Medicine article on skin rashes.
• You are correct ...not usually do a bx unless it is more than a rash. Might want to share article with provider. Yes I d bill the patient because got the treatment but check with the policy first.
• 
  
• Well hope helped you somewhat
• Lady T
  
  
  

 

[thomas7331]

I was told that this is a recent exclusion. The carrier stated it was not an acceptable diagnosis code. However, when I try and locate the LCD on biopsies, there are not any specific to 11102-11107. If the carrier has included they will not reimburse biopsies if reported with rash, is it acceptable to bill the patient?

It's hard to know what a payer means by 'not an acceptable diagnosis code'. As I see it, there could be one of two things going on here. The payer may not consider this diagnosis to be a medically necessary reason to perform a biopsy. If that's the case, there should be a published policy or LCD that specifically states this. Clearly your providers would not agree with this, and it may be possible to appeal the denial. Whether or not you can bill the patient will depend on the payer's guidelines, your provider's contract with the payer, and/or whether or not you have obtained a waiver from the patient. The other possibility is that the payer doesn't consider this diagnosis to be appropriate coding for a biopsy procedure. In that case, I would be arguing with the payer because there is no coding guideline the prohibits the use of this diagnosis with the biopsy codes, and in fact if that's what the record gives as the provider's diagnosis, that's what needs to be coded. In this case as well, you may or may not be able to bill the patient depending on your provider's contractual relationship with the payer.

I'm not aware of any LCDs that actually limit the use of biopsy codes to just certain diagnoses. You might look at the 'benign skin lesions' LCDs, but those usually just involve excision procedures and not biopsies. Biopsies and minor and inexpensive procedures and I can't imagine why a payer would have a problem with this.

 

[Brandy0618]

Hi Brandy,

• The treatment for a rash usually depends on its cause. Options include moisturizers, lotions, baths, cortisone creams that relieve swelling, and antihistamines, which relieve itching. Any change in the skin which affects its appearance or texture. A rash may be localized to one part of the body, or affect all the skin.
• Reference https://www.aafp.org/pubs/afp/issues/2010/0315/p726.html Family Medicine article on skin rashes.
• You are correct ...not usually do a bx unless it is more than a rash. Might want to share article with provider. Yes I d bill the patient because got the treatment but check with the policy first.
• 
  
• Well hope helped you somewhat
• Lady T
  
  

Thank you so very much for this information.

 

[Brandy0618]

It's hard to know what a payer means by 'not an acceptable diagnosis code'. As I see it, there could be one of two things going on here. The payer may not consider this diagnosis to be a medically necessary reason to perform a biopsy. If that's the case, there should be a published policy or LCD that specifically states this. Clearly your providers would not agree with this, and it may be possible to appeal the denial. Whether or not you can bill the patient will depend on the payer's guidelines, your provider's contract with the payer, and/or whether or not you have obtained a waiver from the patient. The other possibility is that the payer doesn't consider this diagnosis to be appropriate coding for a biopsy procedure. In that case, I would be arguing with the payer because there is no coding guideline the prohibits the use of this diagnosis with the biopsy codes, and in fact if that's what the record gives as the provider's diagnosis, that's what needs to be coded. In this case as well, you may or may not be able to bill the patient depending on your provider's contractual relationship with the payer.

I'm not aware of any LCDs that actually limit the use of biopsy codes to just certain diagnoses. You might look at the 'benign skin lesions' LCDs, but those usually just involve excision procedures and not biopsies. Biopsies and minor and inexpensive procedures and I can't imagine why a payer would have a problem with this.

Thank you so much for this information.