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Thread: ICD-9 Help / Dysplastic Nevus Back

  1. #1

    Smile ICD-9 Help / Dysplastic Nevus Back

    Hello Fellow CPC's,
    I am having an issue with the theory behind the coding of a dysplastic nevus of the" back", confirmed by pathology report. I know that a dysplastic nevus has characteristics of a malignant lesion, although it is really not considered malignant. So here is my issue. What code do I use 238.2 or 216.5? My only issue with 238.2 is if you look in the 2010 ICD-9 book under the tabular listing it says right under 238.2 "TIP: Assign this code for keratocanthoma only". That would make me lean towards the other code. Or is keratocanthoma the same thing as a dysplastic nevus (I don't really think so)? Do I ignore this tip in the tabular listing? I was taught that I should pay close attention to all the little notes in the tabular listing because it will help you choose the proper code. Plese help. Which code 238.2 or 216.5?
    Thanks
    Amanda Lewis

  2. #2
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    Hey,

    I think 216.5 is the one!

    A dysplastic nevus (also known as a: Atypical mole, Atypical nevus, B-K mole, Clark's nevus, Dysplastic melanocytic nevus, Nevus with architectural disorder[1]) is an atypical melanocytic nevus;[2] a mole whose appearance is different from that of common moles. Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. Their color frequently is not uniform and ranges from pink to dark brown; they usually are flat, but parts may be raised above the skin surface. Dysplastic nevi can be found anywhere, but are most common on the trunk in men, and on the calves in women.

    Keratoacanthoma (ICD 9 CM code is 238.2) is a relatively common low-grade malignancy that originates in the pilosebaceous glands and closely resembles squamous cell carcinoma (SCC). In fact, strong arguments support classifying KA as a variant of invasive SCC. The pathologist often labels KA as "well- differentiated squamous cell carcinoma, keratoacanthoma variant". KA is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4–6 months in most cases. KA reportedly progresses, although rarely, to invasive or metastatic carcinoma; therefore, aggressive surgical treatment often is advocated. Whether these cases were SCC or KA, the reports highlight the difficulty of distinctly classifying individual cases.

    And hey... paying attention to tabular list is really a good thing, so dont't avoid. Also when you are not coming to any specific code viz., cancer, neo. etc please refer to morphology of neoplasm in ICD 9CM.

    Hope this helps!

    VJ.

  3. #3

    Default

    Thanks a million VJ. I appreciate your response. I was hoping someone would respond to my post. I would have chose the other code,but the tip in the tabular listing makes me skeptical.

  4. #4

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    Check the neoplasm section:

    Neoplasm, skin, back - uncertain behavior - 238.2

    If you wish to use 216.5, 238.2 should be used as a secondary code
    since you are billing from path report, and have a dysplastic diagnosis.

    JAM

  5. #5

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    216.5 is the right code im a derm coder and if the Doc says r/o BCC SCC i would use 238.2 which is uncertain behavior.

  6. #6
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    Quote Originally Posted by randrk View Post
    216.5 is the right code im a derm coder and if the Doc says r/o BCC SCC i would use 238.2 which is uncertain behavior.
    sorry but you absolutely cannot code any condition documented as "rule out". 238.2 is not a dx code to use when the physician indicates uncertainty in the dx. It is a dx code used when the pathologist indicates that the dx is a neoplasm of uncertain Behavior. it is a dx that can be rendered only after examination of cells under a microscope.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7

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    We use 238.2 for Atypical Nevi-since there is no actual dx code our physician feels this is the best fit. Coding 216.xx doesn't show the medical necessity and would most likely be denied by insurance. Atypical Nevi should be removed and are considered medically necessary.

  8. #8
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    Quote Originally Posted by ERINM View Post
    We use 238.2 for Atypical Nevi-since there is no actual dx code our physician feels this is the best fit. Coding 216.xx doesn't show the medical necessity and would most likely be denied by insurance. Atypical Nevi should be removed and are considered medically necessary.
    The dx is the patient's not the physicians therefore you cannot use a dx that the patient does not have just to get a claim paid. You will need to bill the 216.xx and then if it is denied as cosmetic you can appeal.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9

    Smile

    Thanks I appreciate everyone's opinions. It helps me a lot.

  10. #10
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    If the Dr is coding the procedure as a biopsy (11100) then you would not know what the diagnosis was and you would use 238.2 as your diagnosis code.

    If you are coding it with the excision codes 11400 - 11406 then you would use the 216.5 diagnosis code.

    If it turns out to be malignant then you would use the excision codes 11600-11606 and the diagnosis code would be 173.5 for Basal cell carcinoma and Squamous cell carcinoma, and 172.5 for Melanoma, if it is malignant in situ then the diagnosis would be 232.5

    You don't code the excision codes until you have the diagnosis, they will not pay for the unknown diagnosis code 238.2.

    Often my dermatologists will code the biopsy code for the original surgery and then when they do the reexcision to remove the rest of the lesion they will code with the excision codes and by then we already know the diagnosis code and do not have to hold the claim while we wait for path.

    Hope this helps,

    Amber L. Newcomb
    CPC
    Dermatology

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