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Thread: What diagnosis code - We did a biopsy on a Medicare patients

  1. #1
    Join Date
    Apr 2007
    Aberdeen, SD

    Default What diagnosis code - We did a biopsy on a Medicare patients

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    We did a biopsy on a Medicare patients back, pathology came back with “dysplastic nevus fully evolved moderate cytologic and architectural atypia, extending to the lateral margins,” the pathologist used diagnosis code 216.5. The pathologist recommends a small conservative re-excision to prevent recurrence and morphologic progression.

    On a later date we performed the excision, should we use 238.2 OR 216.5 and V49.89. I am leaning towards 216.5 and V49.89. I am referring to the LCD policy L24361. Code 216.5 is a List II code, and I am wanting to use item D or E.

    List II. These ICD-9-CM codes identify those conditions for which payment is allowed only if the conditions have complications, consistent with the provisions noted above in Indications and Limitations of Coverage, items A through H. Providers are instructed that the addition of a second diagnosis code, V49.89 Other specified conditions influencing health status, is required and by using that code, providers will be asserting that their medical record documentation includes verification of the complicating sign, symptom or diagnosis that supports payment for the lesion removal.

    D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction.

    E. A prior biopsy suggests or is indicative of lesion malignancy.

    Whats diagnosis code would you use? Thanks for your help.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    the path report is indicative of a 238.x code for uncertain behavior.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    Aberdeen, SD


    The pathologist dx code sent me on the wrong track. Thank you

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