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Denials from Medicare for fat necrosis - N64.1

Lcubed

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Hello all,

I am hoping for some guidance with a denial for ICD N64.1 = fat necrosis of breast. We consistently see this denial and when I query the pathologist this is the true diagnosis. Most recent example is a patient with current breast cancer = C50.912 with a biopsy for new margins. Diagnosis is N64.1 because margins are negative and specimen is only showing fat necrosis. There is no coding for T85.898 (code first note).

Any help is appreciated.

Thank you!
Laura
 

bbooks

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I'm not sure what you mean by "There is no coding for T85.898 (code first note)." Do you mean that there is no documentation of a breast graft?

I also see fat necrosis with breast specimens, but I don't ever seem to have information on the report about a breast graft. Without that information, and with the code first requirement for N64.1, and if there is no residual cancer to code, I've felt my only other choice was to use N64.89 (Other specified disorders of breast). I'm not aware of any denials associated with this practice.
 

Lcubed

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Sorry if I confused you.

What I meant was that this patient does not have a breast graft.
This was for a re-excision of a previous margin. Patient is still in active treatment for the breast cancer. I had a discussion with my billing company and their coder suggested the "history of code" for breast ca = Z85.3 as primary and then N64.1 as secondary. That doesn't seem correct to me either. I find that the pathology-related questions are hard to find a real answer for and in this case I am just really stumped.

I also get a denials for N64.1 and I believe that it is because of the "code first" note.

I like your suggestion for N64.89.

Thank you for your answer. I really appreciate talking it through.

Laura
 

thomas7331

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If the patient is still in active treatment for cancer, why would you not code the malignancy as your principal diagnosis? That is the diagnosis that is the indication for the excision of the margins. Per the guidelines, when "the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis." You are correct that you should not code the history unless the "primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site" but that is clearly not the case here.
 

bbooks

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Great point thomas7331. Choosing the best code is so dependent upon the clinical information provided.
 

Lcubed

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thomas331 and bbooks I completely agree with your assessment re. the guidelines, however I think that the issue with this case in particular is that this is a Pathology diagnosis. If the case was coded as current breast neoplasm that would NOT be accurate for the pathology diagnosis as it was negative for the margins. The reason that there was a re-excision is to determine if the margins were clear at the histological level and they were. The only thing that the pathologist saw on the slides is what she diagnosed as "fat necrosis".
 

thomas7331

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thomas331 and bbooks I completely agree with your assessment re. the guidelines, however I think that the issue with this case in particular is that this is a Pathology diagnosis. If the case was coded as current breast neoplasm that would NOT be accurate for the pathology diagnosis as it was negative for the margins. The reason that there was a re-excision is to determine if the margins were clear at the histological level and they were. The only thing that the pathologist saw on the slides is what she diagnosed as "fat necrosis".
I guess you'd need to look to your payers' policies for an answer on this then - I'm not sure why a payer would deny a pathology charge for this diagnosis and it doesn't make a lot of sense. I don't work a lot with pathology, but I'm not aware of an LCD or payer policy that limits payment for that type of service based on a diagnosis. Is this denial of a particular test or unusual kind of service that requires certain indication be met? I would think that if there was a policy (and there should bel if the payer is denying the service), it should include some coding guidelines or instructions of what conditions must be met in the record in order to qualify for payment. Sorry not to be able to help much with this.
 
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