Wiki Anatomical Face map?

[sinman0531]

Hey everyone,

I have a provider who performed a MOHs on a patient in early December and based on the photos of the site, it is very clearly the face (the site is on the temple), however, he marked it as "preauricular" on our internal MOHs documentation, in the chart, and on the pathology requisition. If I send the claim out with the diagnosis of C44.212, it's going to deny. However, the regional office manager says there is "nothing they can do" to change the wording because the path report lists the site as "preauricular". I know for a fact they can send a correction to the lab and fix it, and if I tell the doctor that his procedure that cost thousands of dollars was not paid because the record was worded incorrectly he will flip. Does anyone know where I could find an anatomical map of the "regions" of the face? Logic obviously isn't playing a part here, so I have to have hard proof of the difference in locations from a medical perspective (not just my opinion) before I suggest sending the correction.

 

[thomas7331]

First of all, C44.212 is not going to deny, but that's not the code I would use here. "Preauricular" just means 'in front of the ear' - it doesn't mean in or on the ear, so I wouldn't assign C44.212. It's perfectly fine documentation for a lesion that is on that part of the face or close to the temple. You can assign the code for a cancer of the skin of the face. I don't see any reason why the physician would need change the documentation or the pathology requisition in this situation, or maybe I'm not understanding what you're saying here, let me know.

 

[sinman0531]

First of all, C44.212 is not going to deny, but that's not the code I would use here. "Preauricular" just means 'in front of the ear' - it doesn't mean in or on the ear, so I wouldn't assign C44.212. It's perfectly fine documentation for a lesion that is on that part of the face or close to the temple. You can assign the code for a cancer of the skin of the face. I don't see any reason why the physician would need change the documentation or the pathology requisition in this situation, or maybe I'm not understanding what you're saying here, let me know.

You are correct, but I think you're misunderstanding the question. On the original biopsy/path report, the site is "preauricular", so all other documentation has said "preauricular". No photos have been taken until the MOHs procedure, where it is very obvious the site is the temple, which is about 2 inches distal to the ear. I wouldn't classify 2 inches away as "pre" anything. So the problem is if I change it on the claim, the notes won't match and the claim will deny. If I leave it as is, the photos won't match, and the claim will deny. So, I need the documentation to be changed, which requires changing the original path report. The staff doesn't trust anything we coders say without concrete examples/documentation from the AMA or the AAD or similar, so that is what I am looking for.

 

[thomas7331]

I may still be misunderstanding, but I think your medical terminology is off. The temple is not distal to the ear. The preauricular area is just anterior of the ear, toward the cheekbone and below the temple. These areas overlap and I don't see an issue with this - I would code it as part of the face. In any case, if the physician interprets that location to be 'preauricular', I'd let it be. It's the physician's job to diagnose the patient and name the location of the lesion, not the coder's.

As I see it, the code should reflect what is documented, not what it photographed. Interpreting a photograph of the patient is like interpreting an x-ray or any other image - it's not in our scope. It's not going to deny - I've never heard of a payer denying a claim because the diagnosis code didn't match a photograph in the record. Payers may audit a claim to see if the diagnosis and procedure match the documentation, but they're not going to audit a photograph. Even if they did, a skin cancer is still a skin cancer, and the medical necessity of the procedure is still supported.

 

[sinman0531]

I may still be misunderstanding, but I think your medical terminology is off. The temple is not distal to the ear. The preauricular area is just anterior of the ear, toward the cheekbone and below the temple. These areas overlap and I don't see an issue with this. In any case, if the physician interprets that location to be 'preauricular', I'd let it be. It's the physician's job to diagnose the patient and name the location of the lesion, not the coder's.

As I see it, the code should reflect what is documented, not what it photographed. Interpreting a photograph of the patient is like interpreting an x-ray or any other image - it's not in our scope. It's not going to deny - I've never heard of a payer denying a claim because the diagnosis code didn't match a photograph in the record. Payers may audit a claim to see if the diagnosis and procedure match the documentation, but they're not going to audit a photograph. Even if they did, a skin cancer is still a skin cancer, and the medical necessity of the procedure is still supported.

Based on my understanding, the photographs are a part of the documentation as a whole, are they not? I also remember reading something about being able to use photographs in the absence of written documentation or when there is conflicting information to aid in abstracting the diagnosis when the photos have clear landmarks. My job is to make sure the diagnosis, procedure, and documentation all match up--in my practice, about 50% of the time something is mismatched, usually its something simple--they have the site as the medial canthus, the photos show the medial canthus, but the diagnosis code is the nose. But based on your description, the green circle is what "preauricular" could reasonably be classified as, and the red circle is where the site actually is. Now it's true, that site is anterior to the ear itself--but I would not say it's preauricular.

 

[thomas7331]

Based on my understanding, the photographs are a part of the documentation as a whole, are they not? I also remember reading something about being able to use photographs in the absence of written documentation or when there is conflicting information to aid in abstracting the diagnosis when the photos have clear landmarks. My job is to make sure the diagnosis, procedure, and documentation all match up--in my practice, about 50% of the time something is mismatched, usually its something simple--they have the site as the medial canthus, the photos show the medial canthus, but the diagnosis code is the nose. But based on your description, the green circle is what "preauricular" could reasonably be classified as, and the red circle is where the site actually is. Now it's true, that site is anterior to the ear itself--but I would not say it's preauricular.

Photographs (like imaging films, lab reports, medication administration records, etc.) are part of the medical record but are not provider documentation. Per coding guidelines, a diagnosis code can only be assigned from providers' written statements. With the exception of the specific situations given in the guidelines (e.g. laterality, pressure ulcer stages, social determinants of health) I'm not aware of any guidance that allows coders to take information parts of the medical record outside of provider statements. Correcting codes that are not supported by documentation is perfectly within the scope of coding, as is requesting clarification if information is missing, unclear or contradictory. But comparing the clinical information in the record against provider notes generally involves additional training and credentials aside from coding.

As I understand it, preauricular is anterior to (in front of) the ear, not on or in or behind the ear - in your diagram above it would be the area to the left of the drawing of the ear, so only the left-most portion within the green circle but it could also extend outside of the circle toward the eye and nose. I've always coded this as a part of the face, the same coding that I would use for the temple, which is why I think that in this case the physician's documentation is perfectly fine and doesn't need to be changed, and it also doesn't affect the diagnosis coding in any way. But in any case, the physician has the final say here on how they want to document their diagnosis.