Wiki Shave of lesion filed before pathology confirmed scc

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morrisoncamille@yahoo.com

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I have a question about how to file a shave of a lesion. The medical record documents that the diagnosis as D48.5, neoplasm of uncertain behavior. The claim was filed as such. When it was denied because the D48.5 was not an accepted diagnosis for the patient's EEOIC (Worker's Comp.) case, my manager changed the procedure code to a destruction (17272) code (I disagree, as the medical record clearly indicates a shave) and the diagnosis to a SCC (C44.42). The SCC was confirmed by pathology, but only AFTER the claim was submitted. My suggestion is to either have the D48.5 added to the patient's WC case or to file the claim to Medicare (as the EEOIC also suggested).

The main question is: is it permissible to correct a claim to the malignant neoplasm diagnosis once the pathology confirms it. Everything I read says to file the claim with the confirmed diagnosis you have at the time of service otherwise it is best to hold the claim until pathology confirms the lesion type.
 
Neoplasm of uncertain behavior is a diagnosis that can be determined only by pathology and should not be used without a path report. If you look in the code book it tells you this. A shave can be submitted prior to path but the dx code will be the L98.8 since the provider only knows that is a lesion. Or you can wait for the path report and submit with the path diagnosis. So now that you have the path report you use that code and do not add a D48.5 since that is not a diagnosis documented for this patient,
 
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Your reply was so helpful. I just checked the medical record again to assure that D48.5 is what I saw documented. So, I will have to assure that the providers are made aware not to use this code before the specimen is sent to pathology. You mentioned L98.8 as an option. But what about Neoplasm of Unspecified Behavior (D49.2) for use before the pathology report comes back. Is one better to use than the other? Which would be considered coding to the highest level of specificity, would more accurately describe the patient's lesion, and is more likely to be reimbursed?

Also, am I off base? I have not come across any reference which recommends refiling a submitted/rejected claim that has an unknown/unspecified diagnosis with a corrected pathology-confirmed diagnosis (ex: L98.8 or D49.2 to C44.42). I understand that we are to code what is confirmed at the time of service.

Thanks.
 
Neoplasm of unspecified behavior is to be used when a preliminary diagnostic study can indicate that it is a tumor as opposed to say an abscess or a cyst. So in other words they know what it is not but not entirely what it is, a growth of some kind that should not be there. A neoplasm by definition is a growth that should not be there , however without more definitive work up the provider does not have the ability to know malignant, benign, or uncertain so at this point it is unspecified. It is not a valid choice for a skin lesion since a preliminary diagnostic has not been performed, only a visual observation that it is a skin abnormality.
You do not want to assign neoplasm codes of any flavor with out specific workup to indicate that the anomaly is a neoplasm since these codes will assign high risk to the patient by their payer and can have the unfortunate result of increasing their premiums. \
when you say the providers are documenting neoplasm of uncertain behavior I am willing to guess that they are not documenting this diagnosis. However they may be penning that code to their documentation due to being misinformed about that code. Per coding clinic 1st quarter 2012 the provider may not chose a diagnosis code with its standardized description to be the diagnosis. the provider must render the diagnosis in their own words. My guess is this diagnosis has not been rendered by the provider , just the code selected as they were instructed.
I don't know that there is any problem with filing a corrected claim with the pathology diagnosis, however I do not feel this is a good practice to follow as a routine.
 
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