Its very bad practice not to document where it is, especially if its a precancerous lesion..A provider is telling me when they document 17000, they do not have to document the location. Is that correct?
That was my first thought, the malpractice lawsuit isn't going to go well if its not clear what was removed and from where.Its very bad practice not to document where it is, especially if its a precancerous lesion..
Cant half ass with the documentation. You never know when something can become a liability.
Can you provide a link to where we can find the documentation requirements in writing either by carrier or somewhere else? I'm having issues with a provider and he will only make changes to his documentation if it is in writing from CMS or another certified source.CPT 17000 is for destruction of premalignant lesions. Generally 99% of the time, this is actinic keratosis L57.0 for which there is one general code (not site-specific).
Medicare coverage is governed by NCD 250.4
205.4 does not limit coverage by location or site. No biopsy is required as they are generally easy to detect by clinical examination.
AKs most often in sun-exposed areas. Face, scalp, arms, chest.
They are most often frozen of with liquid nitrogen.
In general, for any lesion that is destroyed, you should document location either through a written description (i.e., s, anatomic diagram, or photographs. Quantity needs to be documented and a gross clinical description of the lesion should be entered into the record.
Size isn't necessary for AKs as code selection for 17000-17004 isn't dependent on size. Documenting size is a good practice (or size range even)
Exam: scaly, hyperkeratotic papules with actinic damage on left forehead x 3, scalp x 1, and left cheek x 1. 5 lesions treated
Treatment: Cryotherapy x 5, Acintic keratosis, forehead x 3, scalp x1, LT cheek x 1
Anatomic diagrams are preferred and a few carriers are actually requiring it.