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help with D48.5 excison code HELP

LBernat7

Networker
Messages
65
Location
Wayne, PA
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0
A biopsy was done and the path stated D48.5 description was Clark's Nevus Junctional, with unusual Features Associated Melanoma in Situ cannot be excluded-lesion should be removed completely because early melanoma in situ in association with a nevus cannot be excluded. The lesion extends to lateral margins.

Dr treats this same as malignant excision would be done wants to code 11602 Opinions help any info be great.
 

CatchTheWind

True Blue
Messages
649
Location
Boca Raton, FL
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0
Yes, you can use the malignant excision code.

Per the AMA's "CPT Assistant," August 2000, pages 5-6: "When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathological diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that best describes the procedure as performed should be chosen."
 

Susan

Expert
Messages
463
Location
Chandler, AZ
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0
Yes, you can use the malignant excision code.

Per the AMA's "CPT Assistant," August 2000, pages 5-6: "When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathological diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that best describes the procedure as performed should be chosen."
I would love to know if you have submitted a claim using any of the 116xx codes with a dx of D48.5 and gotten paid. In this situation I would wait for the pathology report to support malignancy prior to submission to the carrier.
 

CatchTheWind

True Blue
Messages
649
Location
Boca Raton, FL
Best answers
0
Yes, we have gotten paid.

It is not necessary to get a pathology report confirming malignancy. On the contrary, CPT Assistant states "choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathological diagnosis."

Some payers may have different rules, and you should check with your payer to be certain. Our Florida MAC says: "The medical record... should indicate the removal of a... moderate to high suspicion lesion with a corresponding pathology report." In other words, you do have to submit a pathology report, but it only has to show "moderate to high suspicion" (ie: D48.5), not definitive malignancy.
 
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