I have a provider who was treating lesions that are clinically consistent with basal cell carcinoma and she is confident it is basal cell carcinoma. She proceeded with destruction without conducting a biopsy and used 17270 destruction malignant lesions. (She used liquid nitrogen). Can you call it malignant if you didn't do a biopsy?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Coding as Malignant Destruction without Biopsy
- Thread starter Brenda88
- Start date
nkrush12
Networker
Per CMS: The medical record/progress note should indicate the removal of a malignant lesion with a corresponding pathology report or a clinical description consistent with a skin malignancy. The size and location of the lesion must be included in the documentation.
Hmmmmm. "Consistent with" is considered an uncertain term and is not sufficient to code that diagnosis for the physician. Interestingly, "evidence of" is NOT considered an uncertain term.
If the documentation states "consistent with" and there is no pathology, I would not code a malignancy diagnosis, therefore a malignancy destruction would not be appropriate.
If the documentation states malignancy without an uncertain term, I would code malignancy destruction with a malignancy diagnosis.
I would also educate my provider.
Here were some other discussions regarding coding uncertain terms:
If the documentation states "consistent with" and there is no pathology, I would not code a malignancy diagnosis, therefore a malignancy destruction would not be appropriate.
If the documentation states malignancy without an uncertain term, I would code malignancy destruction with a malignancy diagnosis.
I would also educate my provider.
Here were some other discussions regarding coding uncertain terms: