Wiki Not medically necessary denial

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Cjones316

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Patient had a lesion removed (shave removal) off of their back, and pathology came back as Basal Cell Carcinoma. We billed 11303 with diagnosis of 173.51 to Medicare, and it was denied not medically necessary. Medical notes were not requested before the denial.

I am currently enrolled and preparing to take my CPC certification exam, so I want to make sure I am not missing anything.

Any suggestions on what the problem could be?
 
It sounds like the patient was there for a lesion bx. If so I bill cpt 11000 with a dx of 173.51. I normally hold the charge until the path report comes back with results.

I would not bill 11303 unless the patient is seen specifically to have a known BCC removed. I know Medicare will pay for 11000 with dx 173.51.

Hope this helps.
 
If the entire lesion was removed, you cannot bill it as a biopsy. A biopsy is when only a piece of the lesion is removed and submitted for path. I would appeal as it was submitted correctly.
Look at the procedure report carefully, if the removal was only to but not through the dermal layer then it is a shave, if the removal was full thickness, meaning throught the dermal layer and to or into subcutaneous tissue the it is an excision.
 
I think the problem may be that 11303 is a benign lesion removal code and you're billing it with a malignant lesion diagnosis, so of course that diagnosis is not going to be included in the benign lesion coverage list. Shouldn't it be recoded with a malignant excision code if it was confirmed as such by pathology?
 
11303 is not restricted to benign pathology it is a shave removal code. You cant use an excision code unless the documentation supports an excision. It is a matter of how much tissue was removed for the category of CPT. For a shave removal the 11303 is the appropriate choice if that is supported by the note for the depth of the removal.
 
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Just on the surface this is an odd denial. Not knowing any details I would suggest this be appealed with the documentation. 11303 with a dx of 173.51 should not hit any edits.
Deb's assertion that 11303 is not reserved for benign pathology is correct.
 
Thanks for all of the input! I did find out that per our LCD's for Ky, 11303 is restricted to benign lesions only. However, per the CPT book it is not for benign lesions only.
 
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