Removal of Cyst

Sarahp941

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I have a Provider who likes to remove cyst by excision, regardless of the medical necessity factors. If the patient wants it removed, it gets removed. During the E/M, it's documented as cyst and defers treatment for another day. Some Providers perform an excisional biopsy and send for Pathology and code it as benign w/Nodule (D49.5), as they "truly don't know it's a cyst or not", they rather have the Path confirm the diagnosis. While others code it as benign excision and use L72.0(cyst). Just trying to see if anyone has any advice. Just trying to keep it consistent, with the amount of Providers as we have. I'm sure it's more of an internal policy, then it is against coding guidelines or medical necessity. Thanks in advance for any help!
 

thomas7331

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I'm not clear about what you mean exactly in saying that your provider excises cysts 'regardless of medical necessity factors'. In my experience working with dermatologists and surgeons, there can be a lot of factors that go into the decisions a provider makes about whether or not to perform an excision or do a biopsy first. These can vary greatly depending on clinical presentation, patient age, comorbidities, location, size and type of cyst, symptoms, etc. And some of it may be just based on how and where and when they were trained, or their personal preference about how they prefer to practice their profession. Physicians spend many years learning how to make these types of decisions and are the ones ultimately responsible for them. For someone without that training, medical necessity is not always easily recognized in a medical record, and physicians aren't required to spell out the reasoning in great detail as long as they are following accepted standards of medical care. And if medical necessity is ever challenged by a payer, it would involve a peer-to-peer review and not be the responsibility of a coder to determine.

My advice is that a coder may make suggestions about adding information to documentation that helps to give clarity to the records about a provider's thinking and reasoning in the decisions they make about medical necessity, and in order to make the records more easily defensible for audits and appeals. However, it isn't our place to challenge the provider's decisions or to say what is or is not medically necessary - doing so is a sure way to get a provider upset with you, as I have unfortunately sometimes learned the hard way. But if this is an area you are curious about, I would recommend you have an open and honest discussion with one of the providers to get their perspective as it can be a very educational experience. They are the experts in medical necessity and would be the best ones to explain the reasons for their decisions.
 

Sarahp941

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Thank you for that advice. I never want to be in a position to "question the thinking" of a Provider, but to only provide positive feedback as to how to better document. I have had other Providers express their concerns on what the true meaning of medical necessity in the coding world vs what a Provider thinks is medical necessity. Ex: removal of cyst, but under the cyst was a Basal Cell(they have seen it all :)). She stated that if she wouldn't have sent to Path and just performed punch excision or excision with no path, we may have not caught that. It's kinda torn by Providers. Some Providers send to Path as D49.5, but another says "oh I know it's just a cyst, I will remove it and not send to Path". (Sorry if that came out wrong). I just want to be able to see both sides and explain it to all Providers so we can create a better protocol. But we all know, that some Providers don't budge in how they think, so I'm treading lightly :)
 

thomas7331

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I hear what you're saying, but would just advise to steer clear of the medical necessity issues as far as what should be done for the patient or why. The question of whether or not to send a specimen to pathology is entirely up to the provider and is not within the scope of coding. In fact, CMS has specifically instructed that tests and procedures should not be ordered solely for the purposes of getting a code. I see a similar thing in my own area now where providers may treat a patient for a tick bite with antibiotics as if treating for Lyme disease without testing the patient to see if they actually have Lyme. This may be acceptable from a medical necessity perspective because there may be no need for the test when the result will not ultimately change the treatment that the provider is ultimately going to choose. From a coding perspective, I would stay away from the treatment decisions and only advise the providers that this rationale should be clear in documentation so that a coder will understand and will know not to report Lyme disease as a diagnosis if it is only suspected or the treatment is preventive or precautionary in nature.

In my experience, these kinds of understandings can only come out of ongoing discussions with the providers which is why I recommend that as the best solution. I might also suggest giving them a copy of the section of the 'General Principles of Medical Record Documentation' from the CMS 1995 E&M documentation guidelines. You'll find this on the second page of the guidelines, and it specifically says that these apply "to all types of medical and surgical services in all settings" and includes, among other good pointers, the instruction that "if not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred." Perhaps another suggestion would be to have the providers review a few of each other's notes from time to time, a sort of internal peer review, and let them decide if each others' notes make sense and clearly support medical necessary from another trained physician's point of view.

A coder's role should be to ensure that the documentation is clear and complete and has the necessary information for accurate reporting of the encounter. Questions of medical necessity are the providers' area and if they want to develop a protocol, that's something they should do among themselves. As a coder, I would stay out of that part of it and just give my input from my own training (i.e., are the records are clear and complete, and do they give you the information you need to properly do your job), and leave the medical decision-making to them - that's what they're paid to do. Good luck and hope this may help some.
 

thomas7331

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Incidentally, (and I know this may be controversial in dermatology) I might just add that the code D49.5, although frequently used for a skin lesion of uncertain diagnosis, is not really correct for this - this code is for a lesion that has been determined by pathology to be neoplastic, but of which is of uncertain histological behavior. It's not correct coding to report a cyst or other lesion that has not been examined by pathology as D49.5, ICD-10 chapter-specific guidelines for neoplasms. It's something you might want to discuss with your providers that also might help clarify the coding situation.
 

Sarahp941

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Thank you again for the information. I have recently suggested the pointer of having the Providers review other notes, to see exams and treatment options from a different Providers perspective. They really liked that idea, so maybe I will bring it up again at my next meeting. I think it could be enlightening to learn from and even give feedback. And yes, I always say if it's not documented, then it didn't happen. They picked up on that really quick when they had to create addendums :) All the Providers have been eager and willing to have open discussions and wanting to learn about coding. It helps them have a better understanding of what I'm looking for with documentation, which we know, may not always be a Providers strong point. The Unspecified codes always seem to be controversial to me. I have brought up the idea of using L98.9 in lieu of D49.2 and D48.5. They've used those codes for years as the "reasonings" for biopsies are to Rule Out...SCC, BCC, Melanoma, etc. So in their eyes, they see the lesion with "neoplastic behaviors", which is why D48.5 is frequently used. I have tried to find good articles that I can present for discussion, that provide a different outlook. If you can recommend anything, that would be great. Thank you again for taking the time to respond and the advice is greatly appreciated!!
 

mitchellde

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First if it is documented as a cyst then that is what must be coded. Second the diagnosis is the patient's not the providers, so when you assign a diagnosis code to a claim then the payer takes that as information about the patient and they can use that to assign risk and for benefit assignment. The coder must be the one that assigns the code based on the provider rendered diagnostic statement not based on the provider's chosen code.
The answer you want may be as simple as the code book.. in the code book under the section heading for neoplasm of uncertain behavior it states:
Categories D37-D44, D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made. ( histologic confirmation is a path report or any report where a pathologist has rendered a diagnosis after viewing the submitted sample under a microscope, for instance it could be a cytology report)
Category D49 classifies by site neoplasms of unspecified morphology and behavior. The term 'mass', unless otherwise stated, is not to be regarded as a neoplastic growth.
** many years ago the AHA coding clinics indicated that in this context the word "mass" is used loosely to indicate any abnormality that has yet to have further refinement by a diagnostic measure such as an ultrasound, so if the provider states skin lesion or abnormality of skin then you would use L98.9. **
In the guidelines it states that code assignment is based on the providers diagnostic statement that a condition exists.
This is not the same as a code choice.
Take the example of the patient where the provider rendered the diagnosis of Charcots Joints in the ankles in a patient with type II diabetes. The code chosen by the provider was A52.16 Charcôt's arthropathy (tabetic), and that is the code the coders used on the claim and the one they submitted on the patients request for disability. However that is not the code for the diagnosis the provider rendered. The office claims that is the correct code because it is the one the provider chose.. So what's the problem??? A52.16 is a code for a disease of late syphilis and not a diabetic complication. The term tabetic means it is due to syphilis and the category A52 is for late syphilis. The point being these were all AAPC certified codes in this office and not one of them thought to actually look the code up and change the code for the claim. the end result is the disability has been denied and now they are all being taken to court because the patient is suing them.
I use this example to point out that you code the correct code based on the rendered diagnosis not based on the providers code assignment.
 
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debbiey

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Debra, this is a great reply as I have the same issues with a ophthalmology plastics M.D. and I am always telling the girls and him that the chart must match what they want me to bill, and don't guess or copy over notes. Act as this is your chart and you wouldn't want anyone guessing on your diagnosis.
 
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