Is pathology needed for biopsies?


Shawnee, KS
Best answers
Hi there - is there a black and white rule anywhere that pathology is required before you bill a biopsy code? I don't want a debate over what diagnosis code should or should not be used, I just need to know if pathology is required to be back before you assign a diagnosis code to a biopsy? I understand if you performed a lesion excision you must have path to determine the correct CPT code. Any help?
No, you don't need path. Most dermatologists use D48.5 (neoplasm of uncertain behavior) as the diagnosis, although theoretically the more correct one is D49.2 (neoplasm of unspecified behavior). Carriers will pay with either one.
It cannot be a neoplasm uncertain without the path report. And it cannot be unspecified with the documentation to show that it is a neoplasm such as tumor. You are not required to wait for the path report for a biopsy but you cannot use a path diagnosis without the report. So you code the skin lesion which is L98.9
Neoplasm Table vs L series

We are having same discussion in our office: for example at patient has a Dermatofibroma and provider determines clinically that it is benign. If you are only supposed to use the table if it is determined via path then the only code left that I can see to use would be L98.8?

By the rule that you only use table for benign via pathology then they would have to biopsy everything. It's just very ambiguous.

Please any thoughts or clarification would be appreciated.
Yes you need pathology to determine benign or malignant or uncertain behavior. You need a preliminary diagnostic interpreted by the provider befor you can use unspecified. A lesion or a mass is not necessarily a neoplasm.

My providers love to use multiple melanocytic nevi. They don't biopsy these. Looking up both of these in tabular direct you to neoplasm table. Now what?

Also I usually will use L98.8 because provider is being specific there is just nothing in icd10 to e more specific. Is this the correct application?

Thank you.
Melanocytic Nevi

No takers on this questions? If we can only use neoplasm table with path report, this means that everything that the provider can diagnose clinically now has to be biopsied? This would be astronomical. Any takers please help. Even the study guide from AAPC for Derm uses D codes and the report does not indicate that it was reviewed by a pathologist. Still searching,think that may become my new name. LOL Thanks to anyone who can help.
No, you don't need path. Most dermatologists use D48.5 (neoplasm of uncertain behavior) as the diagnosis, although theoretically the more correct one is D49.2 (neoplasm of unspecified behavior). Carriers will pay with either one.

After 20 years of experience in dermatology and billing ICD -9 & now ICD-10, I am preparing to take the dermatology specific exam with AAPC. I need some assistance, because I noticed that when we bill our biopsies, we always submitted (238.2) now the D48.5 and have never used the (239,2) or the now D49.2. If I take this exam and answer the questions with D48.5 I would not pass, because everything I see written is we should be billing the D49.2.
I do not see that any LCD exists for the 11102-11107 biopsy codes and have read that carriers will accept and pay for both. I am concerned with ICD-10 now, that we should be billing the proper code D49.2. Is there any reason why we would need to change our billing if we have always billed out this diagnosis code? All the billing education we have received always stated diagnosis code 238.2 or the now D48.5 is the code to use, but since ICD-10 being more specific feel that we should change ??? Any thoughts or suggestions would be greatly appreciated. I know once thing it's going to be hard to train myself to use this code so I can pass the exam.
If you want to be technically correct, use D49.2. As Debra pointed out, D48.5 means that the pathologist has examined the tissue and has determined that there is something uncertain or atypical, while D49.2 means that the clinician doesn't know what it is.
There is a LCD 33445 for services performed on or after 1.1.19 and the D49.2 code is not listed on the document as a covered dx code for biopsy cpt codes 11102 thru 11107-therefore we always bill ours with D48.5 since it is listed as a covered dx on the LCD...