Wiki Re-Biopsy After 5FU

Sarahp941

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Hello! I am trying to find guidance or articles to outline the necessity of a new biopsy for lesions previously treated with 5FU. My Providers will have patients follow-up in 3-6 months (after treating the lesion with 5FU) and then say there are malignant cells present again. Providers want to schedule Mohs right away for "Recurrent xyz". But I tell them they need a new Pathology report due to the lesion being previously treated with 5FU. I cannot find any documentation that says this is required specifically, only that a Pathology report needs to be present to treat malignant lesions. I was always told in coding courses, webinars/seminars, etc., that if the lesion has been clinically treated, we cannot determine (without a new Pathology report) if there are any malignant cells at this present time. Therefore, surgical procedures are not a valid. Any advice would be greatly appreciated. Thanks!
 
Just my opinion here, but I think that you're getting outside of the scope of a coder's responsibility if you venture to tell a physician whether or not they need to perform a biopsy or obtain a pathology report. Although it's generally a standard in medicine to get a pathology report for a confirmation of a malignant diagnosis, that is still a medical practice decision based on the physician's professional judgment and not a coding requirement. And if they do not have a new pathology report, that certainly does not mean that 'the surgical procedures are not valid'. I have no idea where you are getting this - if a provider documents that they performed a procedure, then that's what you have to code. Payers may elect to not cover a procedure or determine that it's not medically necessary in certain circumstances, and may write a policy that states this, but that is a different question from what's appropriate to code. You can't decide that a procedure is not valid and not code it simply because a coder or payer feels that it's not medically necessary. If a physician has previously biopsied and diagnosed this lesion, and is documenting that the cancer is recurrent, then that's what I would use.

Determination of a diagnosis, and the criteria required to arrive at that diagnosis, is the treating provider's responsibility and no one else's. As per the ICD-10 guideline I.A.19., "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis."
 
Hello Thomas! Maybe I asked my question wrong or in a confusing way. What I was asking is if a malignant lesion that was treated with 5FU has resolved, but the patient comes back 3-6 months later and the Provider says there is malignant cells present, is the Provider required to perform a new biopsy? My understanding and what I was taught in various coding/auditing classes, was that if the lesion was clinically treated (5FU) and resolved, then you would need a new Pathology report to document "Recurrent xyz". I always educate Providers with facts from a coding standpoint. I would never interfere with their medical practice decision. I was not trying to imply that the procedure would be invalid from a coding standpoint (we would code based upon the surgical note), but questioning the medical necessity if we didn't have a Pathology report confirming the diagnosis. What if had to send medical records, post-payment chart reviews, RAC audits, etc., and not have a Pathology report to support it? Wouldn't that be the job of the coder to ensure the procedure was medically necessary? I apologize for the confusion of my question. Thanks!
 
Hello Thomas! Maybe I asked my question wrong or in a confusing way. What I was asking is if a malignant lesion that was treated with 5FU has resolved, but the patient comes back 3-6 months later and the Provider says there is malignant cells present, is the Provider required to perform a new biopsy? My understanding and what I was taught in various coding/auditing classes, was that if the lesion was clinically treated (5FU) and resolved, then you would need a new Pathology report to document "Recurrent xyz". I always educate Providers with facts from a coding standpoint. I would never interfere with their medical practice decision. I was not trying to imply that the procedure would be invalid from a coding standpoint (we would code based upon the surgical note), but questioning the medical necessity if we didn't have a Pathology report confirming the diagnosis. What if had to send medical records, post-payment chart reviews, RAC audits, etc., and not have a Pathology report to support it? Wouldn't that be the job of the coder to ensure the procedure was medically necessary? I apologize for the confusion of my question. Thanks!
No need to apologize! But again, I think you're approaching this the wrong way. A question that begins with "is the provider required to perform..." is not one that a coder is qualified to answer. You're not going to find coding guidelines to answer that kind of question. Only the providers have the training to make a medical necessity judgment. It's a misconception that coders need to ensure medical necessity - that just not the case. Coders do need to be aware of medical necessity issues and to advise providers that documentation needs to clearly reflect their assessment and decision making, and also so that they can help providers understand and be aware that a payer may not agree with a particular treatment decision and therefore not cover a particular procedure or test. But ultimately the final decision of what is reasonable and necessary is up to the provider as that's what they're trained for. A coder is only trained to report what a provider documents, not to judge whether or not a service was necessary or required.

These are good questions you're asking, but I would put them to the provider. Let them know that you're understanding has been that a pathology report may be required for a cancer diagnosis and that you have a concern that if audited a payer might question why there wasn't a biopsied done first. If you have a copy of a payer policy that says this, then share it with them, (but honestly, I doubt you'll find one because payers don't get down to this level of detail in payment policies). Ask your providers their opinion on this question and if they think the records would be defensible as they are. But recognize that in the end, it's the provider's call as to whether or not to get a pathology report in this situation. If your providers tell you they're practicing according to accepted medical standards and they feel that their peers would back them up on how they're doing this, then I don't think you have anything to worry about. Hope that helps some.
 
No need to apologize! But again, I think you're approaching this the wrong way. A question that begins with "is the provider required to perform..." is not one that a coder is qualified to answer. You're not going to find coding guidelines to answer that kind of question. Only the providers have the training to make a medical necessity judgment. It's a misconception that coders need to ensure medical necessity - that just not the case. Coders do need to be aware of medical necessity issues and to advise providers that documentation needs to clearly reflect their assessment and decision making, and also so that they can help providers understand and be aware that a payer may not agree with a particular treatment decision and therefore not cover a particular procedure or test. But ultimately the final decision of what is reasonable and necessary is up to the provider as that's what they're trained for. A coder is only trained to report what a provider documents, not to judge whether or not a service was necessary or required.

These are good questions you're asking, but I would put them to the provider. Let them know that you're understanding has been that a pathology report may be required for a cancer diagnosis and that you have a concern that if audited a payer might question why there wasn't a biopsied done first. If you have a copy of a payer policy that says this, then share it with them, (but honestly, I doubt you'll find one because payers don't get down to this level of detail in payment policies). Ask your providers their opinion on this question and if they think the records would be defensible as they are. But recognize that in the end, it's the provider's call as to whether or not to get a pathology report in this situation. If your providers tell you they're practicing according to accepted medical standards and they feel that their peers would back them up on how they're doing this, then I don't think you have anything to worry about. Hope that helps some.
Thank you so much! Your insight is very helpful!
 
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