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239.2 vs 238.2

  1. #11
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    Exam Training Packages
    would "atypical" accounts for uncertain after pathology comes in, and is treating as malignant...in general neoplasm

    Thanks
    MS

  2. #12
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    yes that is an example of uncertain behavior result

    Debra A. Mitchell, MSPH, CPC-H

  3. #13
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    Default Malignant vs. benign CPT
    Hey Debra,
    While we're on the subject of proper use of 238.2, I'm having some issues with the correct coding from a CPT perspective.
    I have researched everything under the sun and am receiving conflicting info. If the path report comes back with Dysplastic Nevus, which CPT ranges would you use for the lesion excision? (I know you know the ranges, but posting this for those that may not: 114XX is benign and the 116XX for malignant.)

    The 6th Edition of the "Principles of CPT" coding states that the CPT codes are chosen based on the "Physician's skill, time, knowledge, NOT the final pathology report". I'm STUNNED at how this could possibly be the direction that the AMA could provide. What would stop a physician from using all (or majority) malignant codes when the path comes back with dysplastic if this is the case?

    Hope this makes sense, and I look forward to your thoughts....
    Becki, CPC, CPMA, CGIC, CHONC, COSC, CPCD, Fellow

  4. #14
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    I am not certain the phrase you are referring to is specific to skin excisions or not. The AMA published a CPT assistant several years ago on this subject and specified that for skin excisions you must wait for the path report before coding the excision code. CPT codes are chosen based on what is documented, and the provider is responsible for documenting their skill time and knowledge involved which is what helps us chose the correct code. For an excision we have the documentation of all of this with the exception of the morphology of the anomaly that we must wait for path, as we can code only what we know, and what we know is it is an excision of a specified area to a specified depth, and specified size of a piece of tissue we do not know anything concrete about, so we hold it and wait to get the last piece of information we need to complete the code.

    Debra A. Mitchell, MSPH, CPC-H

  5. #15
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    I found the verbiage I'm talking about in the Principles of CPT coding, 6th Edition specifically addressing the correct coding of dysplastic nevus/nevi and "neoplasms of uncertain morphology". This is an AMA produced book, so I'm VERY concerned.

    I am reviewing some medical records and the Dr. is requesting a malignant CPT code be billed when the path report comes back as Dysplastic. I don't have anything in hard evidence that says to bill based on pathology report vs. the statement that this "Principles" book is advising. I also checked the LCD for our local carrier and it says the exact same verbiage as the Principles book.

    Here is the excerpt: "choose the correct CPT code based on the manner in which the lesion is excised rather than the final pathological diagnosis." The next line states "The CPT code should reflect the knowledge, skill, time and effort that the provider invests in the excision of the lesion. For example, an ambiguous, but low suspicion lesion might be excised with minimal surrounding, gossly normal skin/soft tissue margins, as for a benign lesion. An ambiguous, buit moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion". If the path comes back as dysplastic, but the Doc used a "malignant" manner/thought process in which to excise the lesion, what grounds do I have?

    I appreciate your brain on this one, lol....I feel torn on how to code these!
    Becki, CPC, CPMA, CGIC, CHONC, COSC, CPCD, Fellow

  6. #16
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    AH! I see what you are referring to... I have the answer you seek! I was not paying attention the first time to the dysplastic path you have. Ok
    1st you must wait for path to code an excision
    2nd your question and the instruction you referr to are specific to a path result, in this case dyplastic nevus which is the same as atypical mole which is the same as uncertain behavior.
    Now in the CPT assistant as with the section you are referencing
    When the path returns as uncertain, then we chose the CPT code based on what the provider thought he was looking at (skill, time , knowledge, expertise), in otherwords if he believes it to be benign then he will take minimal margins to spare a scar, if he feels it may be malignant then he will use more care and take larger margins and more time. So a narrow excision for uncertain pathology is coded as a benign excision, and a wide excision for uncertain path is coded as a malignant excision. So the note the provider writes/dictates must support the excision code based on this criteria of time skill and expertise.
    Hopefully this did not add to the confusion.

    Debra A. Mitchell, MSPH, CPC-H

  7. #17
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    Talk about muddy water, lol...If we wait to bill until the pathology reports come back, and if the reports come back as "dysplastic", you think it's okay to still bill the malignant range (116XX)?

    I was hoping this was more cut and dry, but between the CPT Assistants and this Principles of CPT coding, 6th Edition, I'm more confused than ever. The 5th Edition of this book state to code based off the path report. )(which is very clear, in my opinion.)
    The 6th Edition however, changes it from path report to the "Physician's skill", etc.

    Can the payer/carrier ever argue the coding of a malignant CPT with 238.2 dx code (Path report reflects dysplastic or Clark's Nevi) if this is the case?
    Thanks so much for your help.
    Becki, CPC, CPMA, CGIC, CHONC, COSC, CPCD, Fellow

  8. #18
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    I am in surgical oncology so most patient comes in with an already established cancer or something that is in concern for malignancy and the treatment outcome is to remove so there is no ifs or buts.

    My MD's would take large such as 1 or two cm margins and most of the time down to the subcutaneous of the fascia. We are using the radical 20000 codes for that as these are super wide excision leaving large defects.(ex 12cm).

    On cases where there is an uncertain Dx involved and margins are 1.5 or so, I default to 11600 codes because the work is still for a malignant Dx but not quite extensive.

    So I think it is premeditated how to treat these lesions, types and complexity of such. This is where you get to know your MD dictation/documentation and what they mean. Also put scope of practice in consideration before being accustom to making an idea routine.

    Hope I didn't confuse
    MS



    Quote Originally Posted by beckipoff View Post
    Talk about muddy water, lol...If we wait to bill until the pathology reports come back, and if the reports come back as "dysplastic", you think it's okay to still bill the malignant range (116XX)?

    I was hoping this was more cut and dry, but between the CPT Assistants and this Principles of CPT coding, 6th Edition, I'm more confused than ever. The 5th Edition of this book state to code based off the path report. )(which is very clear, in my opinion.)
    The 6th Edition however, changes it from path report to the "Physician's skill", etc.

    Can the payer/carrier ever argue the coding of a malignant CPT with 238.2 dx code (Path report reflects dysplastic or Clark's Nevi) if this is the case?
    Thanks so much for your help.

  9. #19
    Location
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    All of these dialogues are helping. I was thinking it was a very cut and dry "if path report is dysplastic, code as benign". I'm hearing that this is not always the case. My provider is a Dermatology specialist, and as to be expected, he can't tell if it's malignant or not in a lot of these cases with the atypical mole situation.

    I'm quoting an example of our typical Op Report. Based off this document, would you code from the 114XX range or 116XX? (This particular example doesn't have the Path Report, but let's pretend the path report came back and said dysplatic nevus, just to keep it simple.)

    Pre-Op diagnosis: compound dysplastic nevus with mild atypia
    Post Op diagnosis: same as pre-op

    Operation: Punch excision
    Anesthesia: 1% lido with epi
    Indications: Atypical Mole removal

    Details of procedure:
    LESION SIZE: 6cm
    LOCATION: left heel
    Lesion was cleansed and numbed with 1% lido w/ epi. An 8-o punch was used to excise the lesion. Defect was repaired using 4-0 nylon.

    My Dr. requested CPT codes 11621 and 12001 with diagnosis 238.2.

    Thanks for all of your help!
    Last edited by CoderinJax; 06-27-2011 at 11:42 AM. Reason: spelling
    Becki, CPC, CPMA, CGIC, CHONC, COSC, CPCD, Fellow

  10. #20
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    Quote Originally Posted by beckipoff View Post
    All of these dialogues are helping. I was thinking it was a very cut and dry "if path report is dysplastic, code as benign". I'm hearing that this is not always the case. My provider is a Dermatology specialist, and as to be expected, he can't tell if it's malignant or not in a lot of these cases with the atypical mole situation.

    I'm quoting an example of our typical Op Report. Based off this document, would you code from the 114XX range or 116XX? (This particular example doesn't have the Path Report, but let's pretend the path report came back and said dysplatic nevus, just to keep it simple.)

    Pre-Op diagnosis: compound dysplastic nevus with mild atypia
    Post Op diagnosis: same as pre-op

    Operation: Punch excision
    Anesthesia: 1% lido with epi
    Indications: Atypical Mole removal

    Details of procedure:
    LESION SIZE: 6cm
    LOCATION: left heel
    Lesion was cleansed and numbed with 1% lido w/ epi. An 8-o punch was used to excise the lesion. Defect was repaired using 4-0 nylon.

    My Dr. requested CPT codes 11621 and 12001 with diagnosis 238.2.

    Thanks for all of your help!
    How was the dx arrived at without path? using a punch I would go with the benign series.. I am not certain I would use the 238.2 unless there is a path report.

    Debra A. Mitchell, MSPH, CPC-H

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