Question How should I handle this issue with the doctor and code selection?


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Need advice on how to respond to the provider.

The provider performed a sx to excise a benign lesion (28045) which he coded with D36.10. I changed it to D17.24 based on the results of the path report. The payer is OR Medicaid. The procedure would be paid with the original Dx but not with the updated Dx.

The provider wants to leave it with his original Dx so that the claim will be paid. I want to leave it as the new one b/c that is what it actually is.
I suggested that we leave it with the new dx and appeal any denial on the basis that the procedure was performed based on a covered dx. The provider doesn't want to do this.

How should I handle this?


Laredo, TX
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Hi Lunap99, when it comes to excisions of lesion, you do have to wait for the pathology report to bill for the excision because this also determines the CPT code. For ex., benign lesion cpt code vs malignant lesion cpt code. What you can do is proof to the insurance the medical necessity for needing to remove the lesion in the first place. For example, inflammation, pain to the site, redness and irritation or if the lesion was in a spot that interfered with pt’s daily living.....etc. submit pictures if any were taken. Hope this helps!!!