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awaiting pathology

  1. #1
    Default awaiting pathology
    Exam Training Packages
    When coding an E&M visit for dermatology which involved a biopsy, is it necessary to wait for the pathology before submitting? If so, where is that stated?

  2. #2
    In your ICD-9 book under the Coding Guidelines Chapter 2: Neoplasms it states "To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior."
    Herbie W Lorona Jr., CPC, CPC-H

  3. #3
    Columbia, MO
    If it was a biopsy that was performed then you do not have to wait for the pathology but you may code only for the skin disorder such as 709.8, not a neoplasm. It is when you are coding for an excision that the path result is required before the claim may be submitted, and the reason is that the excision codes come in only benign or malignant flavors. So the difference is what was done:
    Biopsy - removal of a piece of the lesion
    Shave - partial thickness (into the dermis but not thru it) removal of the entire lesion
    excision - full thickness ( thru the dermis, into the subq tissue) removal of the entire lesion.

    Debra A. Mitchell, MSPH, CPC-H

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