Appropriate use of D49.2 and D48.5

cnramsey

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Hi,

I just need to clarify when the provider can use these diagnoses. My understanding is the D49.2 Unspecified behavior can be used when a ie punch or shave bx is sent to pathology. We do not have to wait for the report to bill the punch bx 11104 and D49.2.

If my provider excises a suspicious lesion and sends it to pathology and the report comes back with Neoplasm of Uncertain behavior. We would code the D48.5. Uncertain behavior.

So my question is... can the provider code D49.2 unspecified behavior on an excision that is not send out.

What if my provider uses D49.2 unspecified behavior on a suspicious lesion that is sent to path and it comes back with seborrheic keratosis. Would it be appropriate to still code the D49.2 as the primary diagnosis even though the path report came back with SK?

Thank you,
Nichole
 

mitchellde

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A neoplasm of unspecified behavior is not the same as a suspicious lesion. Many years ago it was explained to me that per coding clinics a neoplasm unspecified was a code that could be used only after a preliminary diagnostic service was performed that was unable to determined the benign/malignant/uncertain behavioral properties. Such as a mass where a preliminary ultrasound shows it is not a cyst or abscess and the provider documents it as a tumor. This then requires further pathology to determine the morphology, and then is coded as a neoplasm with unspecified behavior. think of the unspecified behavior as a stepping stone diagnosis to go from what the provider can see or feel ( lesion, mass) to what pathology will determine it to be.
You should not use the D49.2 for a bx you should use skin lesion (L98.9)
If the provider performs an excision and does not send it out then the question is was an excision really performed? you must have a path report to bill an excision. so no you cannot use the D49.2 . for an excision you hold the claim and wait for the path report, for a shave or bx you can bill with the L98.9 or wait for pathology.
if the path report comes back as an SK then you cannot bill as a neoplasm you must bill as an SK.
The diagnosis belongs to the patient, it is their sample you are sending out (or not), so you must be careful in the diagnosis code choice and be cognizant that the dx code will communicate risk to the patient's carrier.
 

cnramsey

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A neoplasm of unspecified behavior is not the same as a suspicious lesion. Many years ago it was explained to me that per coding clinics a neoplasm unspecified was a code that could be used only after a preliminary diagnostic service was performed that was unable to determined the benign/malignant/uncertain behavioral properties. Such as a mass where a preliminary ultrasound shows it is not a cyst or abscess and the provider documents it as a tumor. This then requires further pathology to determine the morphology, and then is coded as a neoplasm with unspecified behavior. think of the unspecified behavior as a stepping stone diagnosis to go from what the provider can see or feel ( lesion, mass) to what pathology will determine it to be.
You should not use the D49.2 for a bx you should use skin lesion (L98.9)
If the provider performs an excision and does not send it out then the question is was an excision really performed? you must have a path report to bill an excision. so no you cannot use the D49.2 . for an excision you hold the claim and wait for the path report, for a shave or bx you can bill with the L98.9 or wait for pathology.
if the path report comes back as an SK then you cannot bill as a neoplasm you must bill as an SK.
The diagnosis belongs to the patient, it is their sample you are sending out (or not), so you must be careful in the diagnosis code choice and be cognizant that the dx code will communicate risk to the patient's carrier.
Thank you for getting back to me. We are trying to educate ourselves and our providers when this type of stuff happens.

So are you saying if I come in and have a mole removed by excision and nothing is sent out the provider cannot be coded the 11400-11446 code range.
 

mitchellde

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yes an excision is a full thickness removal of the entire anomaly. moles are not normally removed with full thickness depth and then tossed. if it is less than a full thickness removal then it is a shave and you do not need a path report to report a shave removal.
 

cnramsey

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yes an excision is a full thickness removal of the entire anomaly. moles are not normally removed with full thickness depth and then tossed. if it is less than a full thickness removal then it is a shave and you do not need a path report to report a shave removal.
Okay, thank you I understand know what you meant by "If the provider performs an excision and does not send it out then the question is was an excision really performed?". I have one more unanswered question. When is it appropriate to use the D49.2 Unspecified behavior? Should this Dx only be used when they are sending a lesion to pathology? We are starting to do more lesion removals and I'm trying to educate myself on them.

Can you recommend any sites that I can use to educate myself and providers?

Thank you,
Nichole
 

mitchellde

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I honestly never use D49.2 for a skin lesion. Mainly because when you look up lesion, then skin the book directs you to the L98.9 code. Without further testing the provider only knows it is a suspicious lesion. I use the D49 codes only when the provider provides an interpretation of a preliminary test and indicates the patient has a tumor. You must be careful with lesion removals and not indicate a neoplasm without clear diagnostic test results. Patients depend on us to be correct, and when a diagnosis is assigned just for payment purposes it can have devastating results for a patient. The higher the risk indicated by the diagnosis, then the probability of an increase in the patient's insurance premiums is high.
 

cnramsey

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I honestly never use D49.2 for a skin lesion. Mainly because when you look up lesion, then skin the book directs you to the L98.9 code. Without further testing the provider only knows it is a suspicious lesion. I use the D49 codes only when the provider provides an interpretation of a preliminary test and indicates the patient has a tumor. You must be careful with lesion removals and not indicate a neoplasm without clear diagnostic test results. Patients depend on us to be correct, and when a diagnosis is assigned just for payment purposes it can have devastating results for a patient. The higher the risk indicated by the diagnosis, then the probability of an increase in the patient's insurance premiums is high.
Currently we are not using this code. The providers brought it up and we told them we needed to look in to the appropriate use of this code. I personally have never put this code on a visit because I have nothing to support it.
 

ccr888

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Hello Debra!

I have followed other posts you have made about this subject and appreciate your experience and viewpoint. There is a lot of conflicting information out on the internet and the sanity of you pointing out again and again to start coding from the Index (as required by ICD-10-CM guidelines) is worth remembering!

I wonder if you can extrapolate and say more about your interpretation of why the D49 block has an "Includes" listing: "growth" NOS, neoplasm NOS, new growth NOS, and tumor NOS? For me, in a family physician setting, it seems the only way through the ICD-10-CM index to D49.2 would be with a pathology report. Are these terms seen and used and commonly coded in other settings? Would the "NOS" be from a pathologist (I'm trying to make sense of this)?

The doctor I work for talks with his dermatologist friends and concludes it's fine to use D49.2 when sending specimens for biopsy or when referring a patient (I never use it when coding for billing, although I believe my predecessor did so). This has been an ongoing battle for over 1.5 years of my employment here, along with my attempts to educate the doctor regarding the coding guideline differences between hospital and provider office visits! As someone who has worked hard to earn my CPC, the lack of provider (and office manager) education and their fallback to "we've always done it this way" and "we've never had a problem" are frustrating for me.

Thanks for any response/feedback!

Christine
 

mitchellde

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To get to the D49 series vis the index look under key word tumor. There maybe other key words that take you to a D49 but I have not found them. It was a few years back that I read where you can only use neoplasm unspecified after a preliminary diagnostic test has been performed and the provider documents the result as a tumor, or new growth. It is not appropriate to use neoplasm unspecified for skin abnormality that is removed and sent to path. Because what if it is not a neoplasm at all. You cannot put the genie back in bottle, once the payer has the code for a neoplasm of any flavor it is not an easy task to take it back.
 

dkb6126

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This is a good example of why it is best to wait for path to return to bill these excisions.
 
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