medicare denial for lesion excision - Physician excised

[paula f3]

I had previously posted a query in which I did receive an answer. My problem is that we are receiving a medicare denial for not medically necessary.
Physician excised 2 separate lesions, one on the scalp and other on the leg smaller than 1cm, pathology for both reported as hemangioma. I coded DX as 228.01.
Looking at LCD for Az ,228.01 is not a diagnosis showing medical necessity.
Called the physician and they stated they never wait for the path report and they coded as 216.4 and V49.89, and they were paid.
Please help, as I have always been told to code dx off path report.

Paula

 

[mitchellde]

If this was performed as an excision then you are required to wait for the path. The CPT codes for excision only come in benign or malignant flavors. If your provider did perform an excision and is documented that he was suspicious that this might be malignant, then after path use V71.1 for suspected malignant neoplasm not found. This code must be first listed, use the 228.01 secondary. You cannot assign a dx code to the patient that they donot have or is not known at the time the claim is coded.

 

[cynthiabrown]

I know in Illinois they also want a symptom code such as irritated or something. I don't have my book with me but it is in 700.00 codes

 

[ASH527]

I have been getting denials for these also & Medicare is wanting the primary diagnosis and also a secondary diagnosis - the LCD L27362 has all the information - I have appealed my denials with the note and path reports - Good luck