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icd-9 coding for lesion removals

  1. #1
    Default icd-9 coding for lesion removals
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    Here is a question for you.. I look forward to your responses with rationale.

    A patient comes in for removal of a suspicious lesion with irregular borders and change in color. The physician excises and sends it to pathology. At the time of the procedure the icd-9 code was 238.2 neoplasm of uncertain behavior skin based on the fact that we were unsure of the exact nature of the lesion.

    As a coder we are trained to wait for the pathology report to come back so we know whether to use the benign excision codes or malignant excision CPT codes.
    However, in terms of icd-9 code assignment, do you use the 238.2 which was what we knew at the time of the excision or 702.19 Seborrheic Keratosis which was what came back on the pathology report?

    I guess this poses a question for me because if a patient comes in for a regular office visit with knee pain and we send him for an xray we would code 719.46 because that is what we knew at the time of the visit. If the xray came back as a fracture a day later after the claim for the office visit was sent, we wouldn't change the diagnosis for the visit the day before.

    Thoughts....? What comes first, the chicken or the egg?
    Heather Winters, CPC, CFPC

  2. #2
    Columbia, MO
    238.x dx codes are not to be used when you are unsure of what the path will reveal, they are path codes for when the pathologist sees microscopically uncertain behavior in the cells. You are not to code an excision until after the path report so you code from that result. You did not know it was a 238.x at the time of the excision. If you get back a seborrehic Keratosis, then you can use V71.1 as your first listed which shows the medical necessity for the excision.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Icd-9 238.2
    Thanks for you response, however, I'm not sure that's actually correct.

    V71.1 is not listed on any Medicare LCD for benign lesion removals. If we used that code we would never get paid for an office surgery.

    Also, take a look at this LCD

    The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

    Not all of the conditions listed in the Indications section of this LCD represent a specific diagnosis, but may be conditions supporting a diagnosis. For example, if a lesion is excised because of suspicion of malignancy (e.g., ICD-9-CM code 238.2), the Medical Record might include “increase in size” to support this diagnosis. “Increase in size” might also support the diagnosis of disturbance of skin sensation (782.0).
    This does not say that we can only use the code 238.2 if a pathology report states it's uncertain, it says we can use it for a suspicion of malignancy based on clinical findings like change in size.

    I called Medicare and even the person at provider outreach and education couldn't give me a definitive answer about which icd-9 code they would be looking for on the claim.
    Heather Winters, CPC, CFPC

  4. #4
    Columbia, MO
    I use the V71.1 on a regular basis and have never had any problem with reimbursement. 238 can be used for an excision if you have a preliminary biopsy path that indicates uncertain behavior. The ICD codes are not CMS codes they are created by the CDC primarilarly, we cannot change the CDC definitions. 238 codes are morphohistopathologic which means render by pathology after microscopic examination. You need to show the medical necessity for the excision and when path come back as other than malignant then V71.1 fits the bill. You must remember that the patient deserves our best effort to code THEIR diagnosis. Just because a physician does not know prior to excision the morphology of a lesion, does not mean we use 238 since that is a morphologic diagnosis and if you do then you are giving a dx to a patient that they might not have and causing issues down the road for them.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Well that is a reasonable debate. My question is this: Once the path report has come as a "Seborretic Keratosis", should we still use the V code, which says 'suspected malignancy', whereas in our case the crystal clear report is a BENIGN condition?

    SK is noncancerous benign skin growth that originates in keratinocytes and it is more common as the people age.They are unrelated with melanoma.

  6. #6
    Columbia, MO
    The V71.1 says suspected maliganacy NOT FOUND.. so yes it is appropriate after path when the reason for the excision was for suspected malignancy. You must read the V71 category description which goes to each code in the category.

    Debra A. Mitchell, MSPH, CPC-H

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