Wiki Warts - We used to bill our service for wart

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louetta63

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We used to bill our service for wart removal/treatment with the DX code of 078.10 and they were always paid BUT now, all of our Medicaid payors and Medicare will not pay with this DX alone. They sent us to the LCD guidelines in Ohio for warts. There are Group 1 codes and Group 2 codes. In order for them to be considered for payment, we have to use a code out of group 1 along with the code from Group 2 BUT the DX codes in Group 1 (only 12 codes) are NOT warts. Does anyone have any suggestions?
 
List

Group 1 Paragraph: It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The
correct use of an ICD-9-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must
meet the criteria specified in this determination.
The ICD-9-CM codes listed below identify the lesion being treated and will, by themselves, be considered for payment:
Group 1 Codes:
078.0 MOLLUSCUM CONTAGIOSUM
078.11 CONDYLOMA ACUMINATUM
235.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX
236.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED FEMALE GENITAL
ORGANS
236.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED MALE GENITAL
ORGANS
238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
374.84 CYSTS OF EYELIDS
686.1 PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE
702.0 ACTINIC KERATOSIS
702.11 INFLAMED SEBORRHEIC KERATOSIS
Group 2 Paragraph: For the conditions below, a Primary ICD-9-CM code AND a Secondary ICD-9-CM code that represents a complication are required.

Group #2 is quite lengthy and has all of the specified warts listed then.
 
I get it. They do not like your use of unspecified code. This is going to be the norm from now on, it is due to the specificity of ICD-10 CM codes. If you notice the group 1 codes can be used alone. The group 2 codes are probably those that require an underlying condition per ICD-9 convention.
 
Help

But the codes in Group 1 is not related to the Warts and are different procedures and NONE of the ones in Group 1 are considered *warts* - so how do we get warts paid for then? This is so frustrating!
 
The 078.1- codes are wart codes, your provider needs to be more specific with the documentation. A diagnosis of wart is not sufficient for a specific diagnosis code it is too general. You cannot use the neoplasm of uncertain behavior codes without a path report. This will be up to the provider to document. As the coder, if it has been submitted and denied there is nothing that can be done except try to appeal. Documentation cannot be amended after claim submission and denial. If you had an ABN signed by the patient prior to the procedure you could maybe bill the patient, if this is Medicare and the appropriate modifiers were used.
 
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Frustrating

The problem is - that the provider's say that they are just warts due to a virus so what other code would you be able to use? We looked and there is not a specific code?
 
This is the failure of ICD-9 codes, there is nothing you can do, the provider needs to either biopsy the anomaly for a more specific dx or treat it as a cosmetic service and get the waivers signed.
 
You must report a code from Group 2 primary diagnosis codes (eg, 078.10) and a code from group 3 secondary diagnosis codes (eg, 729.5, pain in limb) to meet the coverage criteria. If no group 3 code appropriately represents the complication that is the reason for removal of the wart, then the service is not covered and an advance beneficiary notice should be obtained prior to removal as the service is not considered medically necessary.
 
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