# Basal Cell Carcinoma - physician has handwritten



## sjhazen75 (Jan 7, 2012)

Hi,

I have an encounter form where the physician has handwritten "R Shoulder Basal Cell CA, Basal Cell Excision."  He then circled the CPT code 11400, which is the excision for a benign lesion.  I crosswalked the code to 11600 for the malignancy and billed it out. 

I don't have a path report to review, nor do I have the medical record, although I have requested it.  My assumption is that physicians know when a lesion is obviously a cancerous lesion.  Was I right to bill the malignant code straightaway, since there seemed to be no question in what type of lesion it was?  

Thanks - Sara.


----------



## mitchellde (Jan 7, 2012)

You do not know nor does the physician l=know when a lesion is "obviously" cancerous, they can suspect it but they do not know it.  It can have an appearance consistent with a malignancy but that again is not the same thing.  A neoplasm (cancer) of the skin cannot be known or coded without a path report.  If the provider is doing the excision to determine the morphology then the claim must be held until the path report is obtained.  If this is a re-excision at the same site  of a known basal cell due to positive margins then the path has already been rendered.  *You should never code nor change* *a code without the documentation*.  The diagnosis belongs to the patient, if this turns out to be nothing, you have already communicated a malignancy to the payer and have increased the patient's risk as a beneficiary.


----------



## sjhazen75 (Jan 7, 2012)

Thank you for your response.  I have requested the medical record and will gather more information as to the pathology and history with this patient and submit a corrrected claim if necessary. My question now is, should I instruct my Dr. to bill an uncertain behavior diagnosis code, with a benign excision removal code?  It seems that would be the safest route.


----------



## mitchellde (Jan 7, 2012)

no you do not bill uncertain behavior without a path report.  You do not bill any excision without a path report.  That is why the AMA made the excision codes with only benign and malignant choices.  Do you work for the provider or are you working for a billing service?


----------

