Destruction coding

[hkatie]

I could use some feedback on the following note. What would you code?

"58 year old male comes in for a chief complaint of Lesion on the right temple. Started as a pinkish lesion over 1 year ago. Thought it might have been eczema , treated it with some eczema cream that his wife has, but only helped minimally. Within the last week it started to change - became crusty and itchy; no pain, oozing or bleeding. Pt's wife has been applying a bee's-wax extract. Prone to dry skin; thinks he hay have had eczema in the past.
- H/O of BCC
- No hx of SCC or MM
- No Family hx of skin cancer
-HCTZ
A focused review of systems was performed including Cardiovascular, Constitutional / Symptom, hematologic / Lymphatic, and Integumentary and was notable for general health
good and new skin lesion.
An exam was performed including the scalp (including hair inspection) and head (including face). General Appearance of the patient is well nourished and well developed. Orientation: alert and oriented x 3. Mood and affect: in no acute distress.
Impression/Plan:
Neoplasm of Uncertain Behavior: (patient seen with Dr. XX) ~1.5x1.8 cm red erythematous patch with overlying yellow greasy scale; tender to scraping distributed on the right medial temple.

Ddx includes: Actinic Keratosis w/ secondary contact dermatitis vs. ISK vs. Superficial BCC
Plan: Pt was given the following tx options:
- Observation
- Topical steroid to decrease inflammation and re-evaluate
- LN2
- 5-FU
- Shave Bx
The R/B of each tx were discussed at length with the patient
Plan: Liquid Nitrogen
A total of 1 lesion was treated with liquid nitrogen, located on the right medial temple. The patient's consent was obtained including but not limited to risks of crusting, scabbing, blistering, scarring, darker or lighter pigmentary change, recurrence, incomplete removal and infection.
F/U 3 months to re-check lesion + TSE"

Thanks in advance.

 

[m.edwards]

If the physician is giving this unknown lesion a diagnosis of actinic keratosis with underlying dermatitis vs inflamed SK vs superficial BCC and the liquid nitrogen was used to destroy the actinic keratosis, I would bill it as a destruction of a premalignant lesion. Since actinic keratosis is classified as premalignant, 17000 for a single lesion would be billed out, which covers any destruction method including liquid nitrogen.

When our Dermatologist uses liquid nitrogen to destroy an unknown lesion, however, I bill based on intent. If she is treating the lesion as though it is a benign lesion (possible SK vs VV vs other keratotic lesion), I bill as 17110 with a diagnosis of 239.2. If she is treating it as though it is potentially an early BCC or an AK, I bill as 17000 with a diagnosis of 238.2 for uncertain behavior.

I hope this helps.

 

[mitchellde]

Uncertain behavior is a dx code hat can be assigned only when a path report supports that it is a neoplasm of uncertain behavior, it is not a code for a symptom of a lesion that the provider is unsure of.. 239 for unspecified needs a dx of tumor or growth, lesion or mass is to be coded as that which codes out as a 709.9 for skin lesion. Look in your codebook for these definitions.

 

[hkatie]

Thanks to both of you for your feedback and perspectives.

-Katie

 

[AlaskanCoder]

I concur with Debra on this. Also, beware of diagnoses that are "versus". You cannot code a diagnosis based on intent - in the outpatient setting, you can only code a diagnosis that is confirmed. If a the provider is undetermined on the diagnosis, you must bill signs and symptoms only.

Karen Hill, CPC, CPMA