11301 shave codes Medicare Denials

LBernat7

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Recently Medicare has been denying procedure codes 11300, 11301 etc... all the shave codes. We have never had an issue in the past not sure what is happening now. They are stating that it is not a covered service. We have sent path reports and physician notes and they still deny. Any insite? ICD-10 codes are for Nevus- such as D22.61 or D22.5 etc they are clark's nevus and recommendations from original biopsies are to shave the lesion to the margins as the nevus are compound and extend to one or more lateral margins. and This is for a dermatology practice.
 

LBernat7

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It depends on your LCD. I don't know what state you are in .

Here is a Californhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34233

The codes you show are listed as a List II code (covered), but require a second diagnosis to show medical necessity (from List III).

I hope this helps!
Thanks. Oddly enough for years they have always paid the D22 codes which are Melanocystic Nevus or Dysplastic Nevus specific codes the D23 codes which it looks like they are willing top pay on are actually less specific "OTHER Neoplasm benign" sort of less specific when you think about it. My guys are saying we have always treated the DN's (D22 types) with shave if needed or excision repair if margins warrant. Obviously SHaves are less evasive then Excisions as there is no sutures or deep sutures. I was able to find the info you sent me in the other thread on the LCD for medicare it just seems odd this is all happening all of a sudden. Here is another thought the lab is coding the spot as D22 not D23 but pathology studies warrant the follow up to be a shave not excision, so are we saying the lab also needs to change coding? Any thoughts be very helpful as I take this to the drs
 

ellzeycoding

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This policy is valid for Shave or Excision procedures.

But regardless, you need a secondary code from List III to show the medical necessity for the codes you billed that are in List II.

Easiest List III code to show medical necessity is D48.5 Neoplasm of Uncertain behavior. Add that to your above two ICD-10 codes as a secondary code and you met the criteria.

Method of removal (shave vs. excision) would be dictated by size, agressiveness of lesion, body site, etc. I would say size being the primary reason.
 

LBernat7

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confused? Please help

This policy is valid for Shave or Excision procedures.

But regardless, you need a secondary code from List III to show the medical necessity for the codes you billed that are in List II.

Easiest List III code to show medical necessity is D48.5 Neoplasm of Uncertain behavior. Add that to your above two ICD-10 codes as a secondary code and you met the criteria.

Method of removal (shave vs. excision) would be dictated by size, agressiveness of lesion, body site, etc. I would say size being the primary reason.
We are in PA not CA, I was able to go onto the PA LCD's however. So for example I have a code on my path of D21.6 which is a granular cell schwannoma tumor that's how the lab coded it and dr did excision 11403 with repair. On the LCD list D21.6 doesn't appear anywhere but that is what the spot is. Are you saying I should also add a D48.5 to that as a second dx?

Same question with the Shaves 11301 dx on path is D22.5 also not on the list for that code. What can I do to get this thru to medicare? Do I do the D22.5 like on path and then if I add D48.5 to that it will be ok even tho the D22's are not on the list on that size?
 

espressoguy

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Since you have a definitive dx from pathology, I would think adding D48.5 would be inappropriate.

I would read your LCD very carefully (not just the list of covered dx).

I was surprised at how different the CA LCD was from the WA state LCD. Here in WA state, if the lesion has certain characteristics such as bleeding, intense itching, or pain, then we can add Z78.9 as a secondary dx and the claim will be paid. The CA LCD acknowledges that CMS will pay for these conditions, but, unless I missed something, there is no way to code for these conditions.

Your LCD may be different still.
 

LBernat7

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PA Derm Office Help please

Since you have a definitive dx from pathology, I would think adding D48.5 would be inappropriate.

I would read your LCD very carefully (not just the list of covered dx).

I was surprised at how different the CA LCD was from the WA state LCD. Here in WA state, if the lesion has certain characteristics such as bleeding, intense itching, or pain, then we can add Z78.9 as a secondary dx and the claim will be paid. The CA LCD acknowledges that CMS will pay for these conditions, but, unless I missed something, there is no way to code for these conditions.

Your LCD may be different still.
I understand perfectly what you are saying. For 113... shave codes and 114... excision codes: If you look at the PA LCD on the list of "covered DX" D22.5 D22.62 etc (melanocystic dysplastic nevus) is not on there however D23 codes (OTHER neoplasm) are covered on there. Now the Path report reads D22 and descriptions match dysplastic nevus need to clear margins etc so Dr brings in patient for a shave and Medicare wont now cover the D22 code under those anymore? What can we do to get this covered? Does Pathology need to change their reports to D23? Do we code what we have and the CPT the Dr used and then code something as a secondary code to reflect severity? Any advice on this would be helpful the Physician as well as billing staff is confused
 

ellzeycoding

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I only gave CA as an example because I couldn't tell where you were from.

With the DX you are tring to use as primary, the problem that you have for Pennsylvania is that your specific DX (D22.61) is not listed as a COVERED diagnosis for a exicision of benign neoplasm.

The issue with the List II and List III codes is for a separate problem and I think we both are mixing two different questions and answers here...

So, lets take a step back here...

First, did you do a biopsy PRIOR to doing the excision and repair? I'm going to move forward assuming that you did not.

If you didn't perform a biopsy prior to excision, and the doctor was concerned enough to remove it (suspicious lesion) and didn't know what it was (he/she couldn't specify the nature of the lesion), you could bill an exicision of benign lesion with DX of D49.2 - Neoplasm of unspecified behavior as the primary diagnosis. (Note: D48.5 Neoplasm of uncertain behaviour could also be used, but D49.2 is technically correct, since the provider couldn't specify what it was at the time it was removed. Many carriers accept them interchangeably!) D49.2 is payable as a primary DX for this procedure. You can bill this as the medical necessity reason for the code and as the PRIMARY diagnosis.

You don't necessarily need to wait for confirmatory path to bill the excision of BENIGN lesion.

You could only bill an excision and repair of a MALIGNANT lesion if it's been confirmed by path and comes back with one of the covered diagnoses on the LCD.

Now if you DID to path BEFORE excision and repair and already knew it was D22.61, then you are going to have a problem because this isn't a covered diagnosis for exicsion of a benign lesion.
 

LBernat7

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D22 and D23? please help to clarify

I only gave CA as an example because I couldn't tell where you were from.

With the DX you are tring to use as primary, the problem that you have for Pennsylvania is that your specific DX (D22.61) is not listed as a COVERED diagnosis for a exicision of benign neoplasm.

The issue with the List II and List III codes is for a separate problem and I think we both are mixing two different questions and answers here...

So, lets take a step back here...

First, did you do a biopsy PRIOR to doing the excision and repair? I'm going to move forward assuming that you did not.

If you didn't perform a biopsy prior to excision, and the doctor was concerned enough to remove it (suspicious lesion) and didn't know what it was (he/she couldn't specify the nature of the lesion), you could bill an exicision of benign lesion with DX of D49.2 - Neoplasm of unspecified behavior as the primary diagnosis. (Note: D48.5 Neoplasm of uncertain behaviour could also be used, but D49.2 is technically correct, since the provider couldn't specify what it was at the time it was removed. Many carriers accept them interchangeably!) D49.2 is payable as a primary DX for this procedure. You can bill this as the medical necessity reason for the code and as the PRIMARY diagnosis.

You don't necessarily need to wait for confirmatory path to bill the excision of BENIGN lesion.

You could only bill an excision and repair of a MALIGNANT lesion if it's been confirmed by path and comes back with one of the covered diagnoses on the LCD.

Now if you DID to path BEFORE excision and repair and already knew it was D22.61, then you are going to have a problem because this isn't a covered diagnosis for exicsion of a benign lesion.
Biopsy of Lesion was done on previous date. Path comes back with Dx of D22.5 which is not a covered Dx for Medicare patients. Because of the type of spot it is Dr needs to excise to the margins and do a repair. With this Dx medicare won't cover it. But they will cover a D23.5 for example which according to the Physicians is almost identical or the same thing. What do we do? Do we have the Path changed? Office Procedure here is patient comes in with a suspicious spot. A 11100 bx is done and sent to lab if the spot comes back as needing further excision done we take it from there. They do not like to excise and repair when it's not warranted.
 

ellzeycoding

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You are in a bit of a pickle here.

First, MANY other Medicare carriers DO cover D22.5 and D22.61 as covered ICD-10 codes for benign lesion removal (excision, shave, etc.). Pennsylvania does NOT as you have found.

A couple courses of action.

1. Contact the CMS carrier to see if they will add it to their policy as a coverered diagnosis code citing other carriers (e.g., California) as an example. Here is the contact for Pennsylvania.

vicki.kurland@novitassolutions.com

https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf


2. You can try and appeal citing the provider's determination of medical necessity as why the lesion needed removal, however your chances of overturning the LCD are limited.


3. If you have such a situation in the future and you know the DX isn't covered, you can have the Medicare patient sign an ABN notifying that it may get denied and if so, they may be responsible for the charges if it is deemed medically unncessary.


4. If it's already been billed and denied and an appeal fails, you may be out of luck in this case.


5. I would not change (i.e. override) the diagnosis of the path report in order to get paid. That would be considered Fraud. I feel that asking the path lab to change the DX in order to get paid would also be construed as fraud.
 
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LBernat7

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thanks for the clarification

You are in a bit of a pickle here.

First, MANY other Medicare carriers DO cover D22.5 and D22.61 as covered ICD-10 codes for benign lesion removal (excision, shave, etc.). Pennsylvania does NOT as you have found.

A couple courses of action.

1. Contact the CMS carrier to see if they will add it to their policy as a coverered diagnosis code citing other carriers (e.g., California) as an example. Here is the contact for Pennsylvania.

vicki.kurland@novitassolutions.com

https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf


2. You can try and appeal citing the provider's determination of medical necessity as why the lesion needed removal, however your chances of overturning the LCD are limited.


3. If you have such a situation in the future and you know the DX isn't covered, you can have the Medicare patient sign an ABN notifying that it may get denied and if so, they may be responsible for the charges if it is deemed medically unncessary.


4. If it's already been billed and denied and an appeal fails, you may be out of luck in this case.


5. I would not change (i.e. override) the diagnosis of the path report in order to get paid. That would be considered Fraud. I feel that asking the path lab to change the DX in order to get paid would also be construed as fraud.
Thanks for the clarification
 

rkindlund

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Z78.9

Since you have a definitive dx from pathology, I would think adding D48.5 would be inappropriate.

I would read your LCD very carefully (not just the list of covered dx).

I was surprised at how different the CA LCD was from the WA state LCD. Here in WA state, if the lesion has certain characteristics such as bleeding, intense itching, or pain, then we can add Z78.9 as a secondary dx and the claim will be paid. The CA LCD acknowledges that CMS will pay for these conditions, but, unless I missed something, there is no way to code for these conditions.

Your LCD may be different still.

Good morning!
Where do you find the z78.9 provision on the WA LCD? I haven't been able to locate that. I'm in WA too.
 
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