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Waiting for path before billing biopsy 11100

  1. #11
    Columbia, MO
    Medical Coding Books
    AHA coding clinics are recognized as the authority on coding instructions and information I always defer to them. This is in numerous Coding clinics, refer to the codes in the code book for the coding clinic issue references. We code from provider documentation, he has not given any indication that this is a neoplastic process with unspecified cellular activity, he has described a skin disorder.

    Debra A. Mitchell, MSPH, CPC-H

  2. #12
    For years we were using 238.2, but after a lot of research and information from Susan Ward at the AAPC, correct coding states only use the 238.2 when you have a CONFIRMED pathology diagnosis. I.E. "238.2 is only to be used once a pathologic examination has been completed which has this diagnosis as its conclusion". (so dysplastic, atypical, etc.). Therefore, we now use 239.2... we have NEVER used 709.XX (skin disorder)!!

  3. #13
    Columbia, MO
    I will still maintain that the definition of the 239 does not match the physicians documentation and the physician statement is the only thing we are allowed to code from. The documentation will describe a skin disorder. The diagnosis belongs to the patient, it is inappropriate to assign a diagnosis not supported in the documentation. if the documentation describes a skin disorder then that is what you have you cannot step that up to a code of a higher severity. The aha coding clinics define the 239 as a working diagnosis to be used only after a preliminary diagnostic study has been performed indicating a condition yet unspecified by path. they go on to give the example of a tumor is a 239 dx as it is a neoplastic condition that has not had the benefit of pathology to determine the morhpology. I apolodize for disagreeing with Susan Ward, but I too have performed numerous hours of research and years of experience in cancer research in tumor registry as well as coding.

    Debra A. Mitchell, MSPH, CPC-H

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