Wiki CPT codes: 17000 & 17110

[danetta04]

I work at a dermatology office and we recently had an audit with BCBS. They are doing a special investigation on codes 17000 & 17110. They are requesting us to send in clinic note along with claim form if the patient received these services. . I am now receiving feedback on it and they are denying these codes for medical necessity. I reviewed the physician's notes and the patients are being treated for AKs (L57.0) with 17000 and ISKs (L82.0) or Warts with 17110. This is being stated in the notes as well as the location(s) of the lesions. They are denying for medical necessity. I am not sure what BCBS will need to process these particular codes for reimbursement. Does anyone have any suggestions?

 

[mitchellde]

More than likely they are looking for a somewhat recent biopsy which shows these are Actinic Keratosis or what ever diagnosis you submitted as opposed to cosmetic.

 

[thomas7331]

Your local BCBS plan should have a published policy for benign lesions which would outline what documentation they are looking for to determine medical necessity. If you contact them, they should be able to direct you to their policy, or you may be able to find it on their web site. For example, here is the policy for BCBS of MA: https://www.bluecrossma.com/common/en_US/medical_policies/707 Benign Skin Lesions prn.pdf

 

[danetta04]

More than likely they are looking for a somewhat recent biopsy which shows these are Actinic Keratosis or what ever diagnosis you submitted as opposed to cosmetic.

Thanks! I did not think about that.

 

[ellzeycoding]

Carriers rarely require biopsy proven AKs before destruction with 17000 and liquid nitrogen. By nature they are pre-malignant and likely to turn into squamous cell carcinoma. AKs are easily determined by provider examination and documentation of the characteristics of the lesions (located in sun-exposed areas, scaly, tender. Multiple AKS are also usually present in an affected area and individually biopsying multiple AKs prior to destruction is not cost-effective for most carriers.

Usually, for AKs clinical examination is sufficient.

Remember that ICD-10 states

"19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis."

For comparison, Medicare's (not BCBS) National Coverage Determination policy states AKs are covered without restriction.

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=238&NcaName=Allogeneic+Hematopoietic+Stem+Cell+Transplantation+(HSCT)+for+Myelodysplastic+Syndrome&ExpandComments=y&CommentPeriod=0&NCDId=129&ncdver=1&bc=AiAAAAAAIEAAAA%3D%3D&


In regard to destructions of other benign lesions such as SKs, there are often medical necessity requirements (itching, bleeding, painful, etc.) that should be documented. Medical necessity requirements vary from carrier to carrier.

Again, Medicare LCDs are published and easier to locate for a comparison. I'm not sure where you are located (what state), but here is an example of an LCD for Medicare contractor (again not BCBS), but it shows you w

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34233

Your best defense is to have them show you how/where to locate the published payment policy showing the medical necessity requirements.


AKs should be covered as they are premalignant and have a higher probability of turning into a cancerous lesion such as SCC.

Inflamed seborrheic keratoses (L82.0) are usually covered by themselves without exception because they are inflamed! The inflamed part is the medical necessity.

Locate the policy and go from there!

 

[kheimerman]

Pre-malignant vs Benign DX for 17000 or 17100 CPT

1. Can anyone tell me definitively if DSAP Dx L56.5 is considered pre malignant or benign? We have much disagreement/discussion over this in our clinic even among the Providers. I have researched and all I can find is it considered pre-cancerous but rarely leads to true skin cancer.... we are trying to determine if we should be billing this with the 17000 codes or 17110 codes as I was under the impression only L57.0 (AK) would work for 17000 codes. Thank you in advance for any info as I am new to Dermatology coding.

2. Also, I am wondering about DX L82.0- inflamed SK. We have documentation stating the lesion is "irritated"..., does that qualify as inflamed? When I look up the definition of Stedman's Medical dictionary it says:


inflammation in·flam·ma·tion (ĭn'flə-mā'shən)
n.
A localized protective reaction of tissue to irritation, injury, or infection, characterized by pain, redness, swelling, and sometimes loss of function.

in·flame' v.
The American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.
Cite This Source

 

[ellzeycoding]

As far as DSAP, according to medical literature, it is considered a premalignant lesion.

However, many carriers limit 17000-17004payment to the traditional AK ICD-10 diagnos code of L57.0.

For all MACs, AKs are covered under the national CMS NCD 250.4 and it specifically states Actinic Keratosis

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=238&NcaName=Allogeneic+Hematopoietic+Stem+Cell+Transplantation+(HSCT)+for+Myelodysplastic+Syndrome&ExpandComments=y&CommentPeriod=0&NCDId=129&ncdver=1&bc=AiAAAAAAIEAAAA%3D%3D&



There are LCDs for some carriers (like Noridian) that cover L56.5 (DSAP) using a regular destruction of benign lesion code 17110/17111

Example:

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34233

Regarding L82.0 - check your carrier's LCDs or the commerical carrier's coverage policies.

Irritated doesn't necessarily mean inflamed. Irritated could be just red. or bleeding, or appearing scoriated.

Some list L82.0 (inflamed seborrheic keratosis) as covered without a secondary DX code. Others will accept L82.1 (other seborrheic keratsosis) but with a secondary ICD-10 code to show medical necessity. These are sometimes displayed in Group II requiring a second code from Group III to show medical necessity. The R-codes usually show medical necessity.

Examples:

R20.3 = painful (hyperesthesia)
R58 = bleeding (hemorrhage)
L53.9 = reddening/(inflamed?)
L08.9 = infected

 

[kheimerman]

Benign Lesion(s) Covered Diagnosis

Thank you! I appreciate the info. I did know about using a secondary symptom diagnosis to support rationale for removal of benign lesions, just wasn't sure if irritation was interchangeable with inflamed.
Is there a good ICD 10 for location subject to trauma? I see that a lot in this clinic's provider's notes concerning removal of benign lesions (usually Seb. K or warts)
Thanks Again!