Wiki Please help with this case...ASAP

Create Wiki
Rebecca Pate

Rebecca Pate

Networker
Messages
43
Location
Soperton, GA
Best answers
0
A 68 year old male presents to the dermatologist?s office for a skin cancer screening check following removal of melanoma two years ago. The patient is complaining of a lesion to his nose. He denies any other complaints.

ROS: No fever, no rash, no edema

Exam: Const: Well-nourished male in no distress, vitals normal
Skin: Full head to toe skin exam is normal except for a scar on the right arm from the previous melanoma excision and the nose which shows a small 2 mm pink scaly lesion.

A/P: Discussed the lesion on the nose with the patient for which a biopsy was recommended. I discussed the biopsy with the patient who agreed to have it done today. After informed consent was signed, the patient was prepped and draped and 1.5 cc of lidocaine with epi was injected for anesthesia. Once the area was numb, a small biopsy was taken from the nose lesion and sent to pathology. Minimal bleeding occurred and a Band-Aid was placed. Will contact patient with pathology results and will schedule follow up as needed.

Dx: Skin lesion on nose, pathology pending
History of melanoma
Screening for skin cancer
:confused:
 
sherryv1 said:
you will have to wait for the path report to post charges
Click to expand...

You are not required to wait for the path for a skin biopsy. You use the CPT code for biopsy and the ICD-9 code for skin lesion (709.9) and the Code for hx of melanoma. This is not a screening since the patient has a symptomatic lesion
 
Last edited:
Rebecca Pate said:
A 68 year old male presents to the dermatologist?s office for a skin cancer screening check following removal of melanoma two years ago. The patient is complaining of a lesion to his nose. He denies any other complaints.

ROS: No fever, no rash, no edema

Exam: Const: Well-nourished male in no distress, vitals normal
Skin: Full head to toe skin exam is normal except for a scar on the right arm from the previous melanoma excision and the nose which shows a small 2 mm pink scaly lesion.

A/P: Discussed the lesion on the nose with the patient for which a biopsy was recommended. I discussed the biopsy with the patient who agreed to have it done today. After informed consent was signed, the patient was prepped and draped and 1.5 cc of lidocaine with epi was injected for anesthesia. Once the area was numb, a small biopsy was taken from the nose lesion and sent to pathology. Minimal bleeding occurred and a Band-Aid was placed. Will contact patient with pathology results and will schedule follow up as needed.

Dx: Skin lesion on nose, pathology pending
History of melanoma
Screening for skin cancer
:confused:
Click to expand...
Hey!

I'd code the encounter as such:

ICD-9
238.2
v10.82

CPT
11100

However, may I suggest you ask the provider to document the size of the biopsy and lesion. If the lesion was removed with the bx and you wait for a definitive dx from the path, it's possible to bill for an excision.

I hope I've been helpful :)

Take care,

Christina D
 
douglaCD said:
Hey!

I'd code the encounter as such:

ICD-9
238.2
v10.82

CPT
11100

However, may I suggest you ask the provider to document the size of the biopsy and lesion. If the lesion was removed with the bx and you wait for a definitive dx from the path, it's possible to bill for an excision.

I hope I've been helpful :)

Take care,

Christina D
Click to expand...
You cannot use 238.2 without a path report that indicates the cells are of uncertain behavior. These are patient codes not provider encounter codes. If the entire lesion is removed then it is not a bx it is a removal either by shave or excision. A bx is a piece of the lesion removed.
 
many times patients come in for their Full Body Skin Checks and in the process of the full body some lesions are found that need biopsy, those they are not the cc of the day they are sent off for biopsy in that case can't you bill for the encounter with the doctor V76.43 and if they have a HX then bill that like V10.82 or V10.83, V13.3 in the OV code like 99212 or 99213 then bill for the bx 11100 or if more then one add 11101?
 
You must log in or register to reply here.
Top