# New LCD from NGS for Lesion Removals



## heatherwinters (May 13, 2009)

Has anyone had a chance to review the new LCD from NGS on Lesion Removals.  According to them, pathology does not determine code selection.  I was always taught to wait for the pathology report to come back before I code lesion removals.  See this excerpt from a recent article from G. John Verhovsek, MA, CPC located at http://www.surgistrategies.com/articles/skin-lesion-coding.html 
"Because CPT classifies lesions as either “benign” or “malignant,” you should always wait for the pathology report before selecting CPT or ICD-9 to describe the excised lesion(s). There is a single exception to this rule: If the surgeon performs a re-excision to obtain clear margins at a subsequent operative session, you may report automatically the same malignant diagnosis you linked to the initial excision. This is true even if the pathology report on the second excision returns benign, because the original reason for the re-excision was malignancy."​
However, now I have received the following from NGS stating that pathology does not change procedure performed.  Tell me, if we do not have a pathology report, how do we know if lesion was benign or malignant and which codes to select??
*Subject:* Part B News: Medicare Providers Who Bill for Removal of  Lesions (Article Revision)

 Revised Coding  Information for Removal of Benign Skin Lesions

*This  article replaces the Listserv article distributed on April 13, 2009. These  instructions apply to providers who submit Part B claims. Additional guidelines  applicable to Part A claims will be provided in a separate  notice.*

Recent  medical review of documentation has indicated an educational need with regards  to the reporting of removal of lesions. The local coverage determination (LCD)  and coding article (SIA) for Removal of Benign Skin Lesions (L27362/A47397) will  be revised on June 1, 2009 and will include revised  guidelines.

If a  benign skin lesion excision was performed, report the applicable CPT code, even  if final pathology demonstrates a malignant or carcinoma in situ diagnosis for  the lesion removed. The final pathology does not change the CPT code of the  procedure performed. An ambiguous but low suspicion lesion would be reported as  a benign lesion (codes 11400-11446) reflecting the procedure that was performed.  A moderate-to-high suspicion lesion may be reported as a malignancy (codes  11600-11646), if the  appropriate  excision was performed.

To  report removal of lesions of uncertain morphology, prior to identification of  the specimen, report ICD-9-CM code 239.2 (neoplasms of unspecified nature, bone,  soft tissue, and skin), or ICD-9-CM code 709.9 (unspecified disorder of skin and  subcutaneous tissue) since proper coding requires the highest level of diagnosis  known at the time the procedure was performed.” (ICD-9-CM code 709.9 will be  added to the list of payable diagnoses in the LCD.)

Providers  who submit claims to Medicare for excision of lesions should become familiar  with the revised LCD which became effective March 1, 2009 and with future  revisions.

Thank you,

National  Government Services, Inc.

Corporate Communications

​


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## lring (May 13, 2009)

*new to me*

I have not seen this - this is going to be a real problem getting my practices to change the process of holding until for path report!

Thanks for the update!

Lynn Ring


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## heatherwinters (May 13, 2009)

*Path Report no determining factor in lesion code selection*

I guess I am not sure how they feel we should determine whether a CPT code should be used that shows benign or malignant lesion if we do not wait for the pathology results.  I can see where many providers would code for benign without positive pathology report, and that would probably save Medicare money, however, what if providers decide to bill for malignant codes and the pathology report comes back benign.  Very confusing.


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## bella2 (Jun 11, 2009)

This is so strange if we are required to code to the highest level for Dx, it dosen't make sense not to wait for a pathology report


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## heatherwinters (Jun 11, 2009)

*Ngs*

I sent an e-mail and received a response back from   Jennifer Godreau, CPC, CPEDC,Managing Editor,The Coding Institute - Eli Research, Inc.  She indicated that she will be speaking with John Bishop, who is a PA and coding expert in this area, to give his opinion and will talk to Jill Young, who gives coding talks on the neoplasm table, to weigh in.  I have asked her to let me know what their responses are.  

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## mitchellde (Jun 11, 2009)

I have read this at least a thousand times now and I keep coming back to the first sentence:
If a benign skin lesion excision was performed, report the applicable CPT code, even if final pathology demonstrates a malignant or carcinoma in situ diagnosis for the lesion removed.

Ok so if we do not have the pathology then how would we know it was benign???????

I personally am not changing my practice of waiting for the path report.. after all the diagnosis belongs to the patient and the not the payer, the govenment or the provider and I feel we have the duty to assign the most accurate dx code possible without guesing!


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## heatherwinters (Jun 11, 2009)

*lesion removal*

I agree, I think this is an attempt to have the coding of all lesion removals of unknown behavior at the time of excision billed as benign with a 238.2 (that is all we know without a pathology report) in an attempt to lower the amount that they have to pay for reimbursement.  Going by this LCD, if the lesion comes back as malignant, this is not supposed to affect CPT code assignment because we did not know the lesion was malignant at the time of excision.

"If a benign skin lesion excision was performed, report the applicable CPT code, even if final pathology demonstrates a malignant or carcinoma in situ diagnosis for the lesion removed. The final pathology does not change the CPT code of the procedure performed."


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## mitchellde (Jun 11, 2009)

With the exception that we do not even know 238.2!  That dx must be drived from path as well it indicates microscopic examination which reveals celluar activicy wich is uncertain as to its behavior.  This category of dx codes is widely misunderstood.  The CDC and cooperating parties establish this dx many years ago, admitidly before many of our current diagnostic capabilities existed,  for when a pathologist was unable to determine the behavior.


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## heatherwinters (Jun 11, 2009)

*238.2*

"To report removal of lesions of uncertain morphology, prior to identification of the specimen, report ICD-9-CM code 239.2 (neoplasms of unspecified nature, bone, soft tissue, and skin)"

It sounds as if they don't really care what the morphology is.  Based on this guidance, I am very confused about how they really expect us to code lesion removals both in terms of CPT and icd-9 code assignment, and since you are supposed to code the same way for everyone and not base your code assignment on insurances, do I have to change the way I code lesions for the entire practice or just for Medicare?

Here is the LCD
http://www.ngsmedicare.com/NGSMedicare/lcd/l27362_active_lcd.htm


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## mitchellde (Jun 11, 2009)

I know I read the LCD and I was just horrified and confused!  However if you look close they are saying to use 239 codes for unspecified when you are uncertain; which btw is suppose to be after a preliminary diagnostic reveals a tumor or such, in other words the physician is now certain of what the anomaly is not.  While it is still incorrect it is not as bad as uncertain behavior.  It just looks to me like they want us to use our best guess and I just cannot do that. I will still work mine the way I know best and that is code what I know and never guess!


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## heatherwinters (Jun 23, 2009)

*NGS and Lesion Removals*

NGS plans to rescind the LCD advice about lesion excisions.  Read the attached link article.  It also states that on CMS Web Site "superceded" is written in red across the lesion excision LCD



http://codingnews.inhealthcare.com/...-ngs-directives-vs-proper-skin-lesion-coding/






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## mitchellde (Jun 23, 2009)

I spoke with John Verhoveshek at the AAPC a couple of weeks ago and he confirmed that it had been rescinded.. I put a post on this, I forget which heading I put it under.  I should have attached one here too, Thanks Heather for passing the info along.  He said the AAPC was instrumental in having this rescinded.
Debra Mitchell, MSPH, CPC-H


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## cpccoder2008 (Jun 24, 2009)

However, now I have received the following from NGS stating that pathology does not change procedure performed.  Tell me, if we do not have a pathology report, how do we know if lesion was benign or malignant and which codes to select??
*Subject:* Part B News: Medicare Providers Who Bill for Removal of  Lesions (Article Revision)

 Revised Coding  Information for Removal of Benign Skin Lesions

*This  article replaces the Listserv article distributed on April 13, 2009. These  instructions apply to providers who submit Part B claims. Additional guidelines  applicable to Part A claims will be provided in a separate  notice.*

Recent  medical review of documentation has indicated an educational need with regards  to the reporting of removal of lesions. The local coverage determination (LCD)  and coding article (SIA) for Removal of Benign Skin Lesions (L27362/A47397) will  be revised on June 1, 2009 and will include revised  guidelines.

If a  benign skin lesion excision was performed, report the applicable CPT code, even  if final pathology demonstrates a malignant or carcinoma in situ diagnosis for  the lesion removed. The final pathology does not change the CPT code of the  procedure performed. An ambiguous but low suspicion lesion would be reported as  a benign lesion (codes 11400-11446) reflecting the procedure that was performed.  A moderate-to-high suspicion lesion may be reported as a malignancy (codes  11600-11646), if the  appropriate  excision was performed.

To  report removal of lesions of uncertain morphology, prior to identification of  the specimen, report ICD-9-CM code 239.2 (neoplasms of unspecified nature, bone,  soft tissue, and skin), or ICD-9-CM code 709.9 (unspecified disorder of skin and  subcutaneous tissue) since proper coding requires the highest level of diagnosis  known at the time the procedure was performed.” (ICD-9-CM code 709.9 will be  added to the list of payable diagnoses in the LCD.)

Providers  who submit claims to Medicare for excision of lesions should become familiar  with the revised LCD which became effective March 1, 2009 and with future  revisions.

Thank you,

National  Government Services, Inc.

Corporate Communications

​

Did you recieve this directly or did you find this somewhere's ?
  [/QUOTE]


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## LTibbetts (Jun 24, 2009)

Deb, is this the information you told me about last week (re: LCD and disagreeing with it) somewhere in another post? I have forwarded it to my supervisors as I agree with you and I was VERY uncomfortable changing our way of doing things and coding something before we even knew what it was. Unfortunately, our supervisors don't always have our back so I just go with "I am not comfortable putting my name on that" and pass it off to another coder who is willing to it. Not the best practice, I know, but at least it covers me and my integrity.

Heather, thanks for the update and the link!


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## mitchellde (Jun 24, 2009)

Yes this is the one and there is one after this one which has effective date of June 5th I think wich basically rescinds this one.  Mr. Verhovechek agreed with me in that this is very poorly worded and goes against the grain of everything we have been taught.


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## heatherwinters (Jun 24, 2009)

*Ngs*

NGS is still showing the LCD with this wording as active

http://www.ngsmedicare.com/NGSMedicare/lcd/L27362_active_sia.htm


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## cpccoder2008 (Jun 24, 2009)

Which states does this apply to ?


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## mitchellde (Jun 24, 2009)

I know it still shows as active they do not usually do not erase or obliterate the old ones which is unfortunate.


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