# 239.2 vs 238.2



## Beth Coccia

2 of my derm. docs. are ?ing using 238.2 or 239.2.  ICD 9 states 239 "neoplasms of unspecified nature" category 239 classifies by site neoplasms of unspecified morphology and behavior.  238 states "neoplasm of uncertain behavior of other and unspecified sites and tissues.  As far as reimbursement which one is the more approriate code to use?


----------



## LadyT

I wait till pathology comes back then use the pathology diagnosis and 239.2 as sercondary. as it was unspecified when biopsy was done. This is also the way our  dermatology academy tells us to code. Hope this is helpful.


----------



## mitchellde

If you wait for path then you code from the path you would not use the 239.2 code as well.
239.x codes are referred to as a working dx.  It is the code that can be used once a preliminary diagnostic study such as a CT scan renders a diagnosis of a tumor.  This then is classified as a neoplastic process that needs further study to determine the morphology.
the 238.x codes may be used after pathology renders the diagnosis of uncertain behavior.  
A biopsy is a removal of a piece of the visible anomoly and does not require pathology for claim submission but you cannot use a 238.x or 239.x code you need to code the skin disorder usually from the 709.x category.
A shave is a removal of the entire visible anomoly but only to a depth of partial thickness which is into the dermis but not through it.  You also do not have to wait for a path report but again not a 238.x or 239.x.
An excision is a removal of the entire visible anomoly to a depth of full thickness which is through the dermis and to or into the subcutaneous layer.  You must wait for the path report before the claimmay be coded and submitted.


----------



## LadyT

Per The Coding Institute's Dermatology Coding alert newsletter September 2010 Volume 6, no 9  It states you should wait for pathology and also states that 238.2 is used only  when the pathologist is uncertain or the cells of the lesion are of mixed types.  ICD -9 code 239.2 states neoplasm of unspecified nature, that is what the lesion is until I hear back from path. I do use the 709.x series if the pathologist states it is a skin disorder and not a neoplasm. I f path states neoplasm I use the 172.x maglignant neoplasm of skin based also on the skin location.


----------



## mitchellde

I agree with the 238 it is as I stated above a diagnosis rendered by a pathologist.  My infor mation for the 239 comes from AHA coding clinics.  The physician examining the lesion is the one that documentes a skin disorder which is what you have until the pathe report states otherwise.  A neoplasm can be either benign, malignant, or uncertain, that is the cell type which is why it must be rendered by a pathologist.  I am not sure what you mean when you say the path states neoplasm you use a malignant code.  the path should state malignant or benign or uncertain, and you will code accordingly.  
According to the AHA to use a 239 you must first have a preliminary study to show that all other posibilities have been ruled out such as a cyst or an abscess, so that what the provider now knows it that this is a new growth that has yet to be determined as to type, that is why they referr to it as a working dx.  You are not allowed to assume that a lesion or a mass is a neoplastic process.


----------



## mjl903

*238 vs 239*

What would you use if the Doctor is not sure what the neoplasm is but is not doing a biopsy at this time?  I thought that you use 239 before the biopsy and 238 after the biopsy if the biopsy still comes back as uncertain.


----------



## mitchellde

If he is examining a skin lesion the it comes under skin disorder which is a 709.x , if it is something he/she can feel say under the skin then it is a mass or a lump.  As I stated per coding clinic a 239 is after a preliminary diagnositic returns a diagnosis of a tumor and a 238.x is when pathology reveals uncertain behavior as the diagnosis.


----------



## mjl903

*238 vs 239*

Would I use the 709 code if the doctor is doing a biopsy at a different visit (1 week away)?


----------



## mitchellde

yes until pathology sates a different diagnosis


----------



## mjl903

*238 vs 239 vs 709*

That is great information!  I will print this out for future reference.  Thank you!!


----------



## surgonc87

would "atypical" accounts for uncertain after pathology comes in, and is treating as malignant...in general neoplasm 

Thanks
MS


----------



## mitchellde

yes that is an example of uncertain behavior result


----------



## CoderinJax

*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....


----------



## mitchellde

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.


----------



## CoderinJax

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!


----------



## mitchellde

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.


----------



## CoderinJax

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.


----------



## surgonc87

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





beckipoff said:


> 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.


----------



## CoderinJax

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!


----------



## mitchellde

beckipoff said:


> 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.


----------

