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diagnosis coding for biopsy

  1. #1
    Default diagnosis coding for biopsy
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    Patient comes in and has a biopsy I was taught in class to wait until the Path is recd back to bill with the correct dx. The physician I work for states we should bill with d48.5, Neoplasm, uncertain behavior. Which is correct and what do you do? If anyone knows where I can find it in black and white to show that would be great.

  2. #2
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    You cannot use D48.5 without a path report that indicates uncertain behavior. Look in your code book under the sub chapter heading for the D47-D48 section. I.e. Histologic confirmation of whether the neoplasm is malignant or benign cannot be made.
    Histologic confirmation is a path report. You can use as a dx code the skin lesion. Look under lesion then skin and you get L98.9.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    You can also use D49.2 "neoplasm of unspecified behavior." That's the more "technically correct" version of the more common "neoplasm of uncertain behavior." Both codes are used commonly for biopsies, and there is controversy about whether you need to use D49.2 rather than D48.5. The AAD says it's okay to use either one. I am not aware of any source that maintains that these codes should not be used for biopsies.
    Last edited by CatchTheWind; 12-22-2015 at 08:52 AM.

  4. #4
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    The definition in the code book for these codes indicates that for uncertain behavior you need histologic confirmation and this a path report. For unspecified you need a preliminary dx of a tumor or new growth. It tells you the term "mass" (in quotes this means mass and other similar term like lump or lesion) is not to be regarded as a neoplasm unless otherwise documented by the provider. So for the biopsy which is a preliminary diagnostic study, you use what the provider documents as a lesion or mass.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    What code book are you referring to? It's not in my ICD-10. I'd like to look at that!

    Thanks!

  6. #6
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    It is in evey code book that I have looked at. Look at the sub section for neoplasm of uncertain behavior and again at neoplasm unspecified.
    Neoplasm of Uncertain Behavior (D37-D48)
    Note: Categories D37- D48 classify by site neoplasms of uncertain behavior, i.e. histologic confirmation whether the neoplasm is malignant or benign cannot be made.
    Neoplasms of unspecified behavior (D49)
    Note: 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.
    Includes: “growth” NOS
    neoplasm NOS
    new growth NOS
    tumor NOS
    In addition coding clinics stated that you would need to a preliminary diagnostic study interpretation to use unspecified. It is unspecified because without more definitive study the provider has no way to know benign, malignant or uncertain behavior. However from the preliminary study the provider has ruled out all other possible diagnoses.
    Last edited by mitchellde; 12-22-2015 at 04:16 PM.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    Someone correct me if my thought are off base but I'm hoping i'm not the only one who is a little nervous about the fact there are physician that deals with skin cancer who don't know the difference between, Benign, Malignant and Uncertain behavior?
    CPC-P-A (11/2016), COC-A (9/2016), CPC-A (11/2015), PAHM (2010)
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  8. #8
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    No physician would know based on sight whether an abnormality is benign, malignant or uncertain behavior. It always take a histologic study via microscope to know the difference.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    Debra, i was referring to not realizing Uncertain behavior is an actual status between benign, in-situ and malignant.
    CPC-P-A (11/2016), COC-A (9/2016), CPC-A (11/2015), PAHM (2010)
    Fee Schedule Configuration Specialist - Remote

    15 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

  10. #10
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    Apologies and I agree. Although it may be due to misunderstanding of the code for uncertain behavior. Some coders as well as physicians have mistakenly interpret this to mean that the provider is uncertain as to what they are looking at. They do not realize that these codes were created to indicate patient diagnosis, not provider thoughts.

    Debra A. Mitchell, MSPH, CPC-H

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