Wiki Basal Cell Carcinoma - physician has handwritten

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sjhazen75

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Hi,

I have an encounter form where the physician has handwritten "R Shoulder Basal Cell CA, Basal Cell Excision." He then circled the CPT code 11400, which is the excision for a benign lesion. I crosswalked the code to 11600 for the malignancy and billed it out.

I don't have a path report to review, nor do I have the medical record, although I have requested it. My assumption is that physicians know when a lesion is obviously a cancerous lesion. Was I right to bill the malignant code straightaway, since there seemed to be no question in what type of lesion it was?

Thanks - Sara.
 
You do not know nor does the physician l=know when a lesion is "obviously" cancerous, they can suspect it but they do not know it. It can have an appearance consistent with a malignancy but that again is not the same thing. A neoplasm (cancer) of the skin cannot be known or coded without a path report. If the provider is doing the excision to determine the morphology then the claim must be held until the path report is obtained. If this is a re-excision at the same site of a known basal cell due to positive margins then the path has already been rendered. You should never code nor change a code without the documentation. The diagnosis belongs to the patient, if this turns out to be nothing, you have already communicated a malignancy to the payer and have increased the patient's risk as a beneficiary.
 
Thank you for your response. I have requested the medical record and will gather more information as to the pathology and history with this patient and submit a corrrected claim if necessary. My question now is, should I instruct my Dr. to bill an uncertain behavior diagnosis code, with a benign excision removal code? It seems that would be the safest route.
 
no you do not bill uncertain behavior without a path report. You do not bill any excision without a path report. That is why the AMA made the excision codes with only benign and malignant choices. Do you work for the provider or are you working for a billing service?
 
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