# Schwannoma



## stogsmom3 (Oct 25, 2017)

Pre-OP Diagnosis:  Scalp cyst
Post-OP Diagnosis: Scalp cyst

The surgeon did a simple excision of scalp cyst.  Sent to path.  The path returns as a Schwanomma.  I've recieved denials for these.  I've never seen this diagnosis until this last month.  And now this is the 3rd one.  And on each excision, the procedure documented is truly a simple excision.  

Any ideas.


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## ellzeycoding (Oct 25, 2017)

You can use a benign excision code.   You can also code with D49.2 to show medical necessity. (Be sure your carrier recognizes D49.2 vs. only D48.5 and vice versa). For most benign skin lesion removal policies, you don't have to show the final diagnosis on the claim.  The fact that the provider was unable to specify the nature of the lesion (and has concern) is enough to justify the removal with D49.2.   (Some carriers also have documentation requirements, itchy, painful, bleeding, etc. for certain conditions.)

Incidentally, this condition is coded in ICD-10 as D36.11

http://www.icd10data.com/ICD10CM/Codes/C00-D49/D10-D36/D36-/D36.11

Approximate Synonyms
Benign neoplasm face, peripheral nerve
Benign neoplasm head, peripheral nerve
Benign neoplasm neck, peripheral nerve
Benign neoplasm of autonomic nerves of head and neck
Benign neoplasm of peripheral nerves of face
Benign neoplasm of peripheral nerves of head
Benign neoplasm of peripheral nerves of neck
Benign neoplasm, autonomic nervous system of head
Neurofibroma of face
Neurofibroma of head
Neurofibroma of neck
Neurofibroma, face
Neurofibroma, head
Neurofibroma, neck
Schwannoma of face
Schwannoma of head
Schwannoma of neck
Schwannoma, face
Schwannoma, head
Schwannoma, neck


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## mitchellde (Oct 25, 2017)

you cannot use a d48.5 without a path repot.  This code was not created for when your provider is not sure what the final dx will be, it was created for use when the pathologist is unable to determine whether the neoplasm is malignant or benign.  the code book does contain this instruction.. it states:
•Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.  Histologic confirmation means the sample has been reviewed by a pathologist under a microscope.
schwannoma can be either benign or malignant although benign is more common.  prior to pathology if you are wanting to code this, for this example since the provider did render a dx of cyst on scalp then that would be the appropriate code.


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## ellzeycoding (Oct 25, 2017)

Yes, you are correct.  Technically, D48.5 is when the dermatopathologist is uncertain as to the nature of the lesion (malignant vs. benign) or there is uncertainty if the benign lesion will become malignant.  D49.2 is when the provider is unable to specify what the lesion is at the time of the encounter.

Some carriers accept both for medical necessity of benign lesions.  However, a few carriers will only accept one vs. the other per the LCDs.

I clarified my post to indicate D49.2.  However some carriers don't recognize D49.2 with certain benign skin lesion removal policies.


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## mitchellde (Oct 26, 2017)

I am not sure what you are saying here.  A coder cannot select a patient's diagnosis code based on what the LCD states it will pay.  If there is no path report stating uncertain behavior then the coder cannot use that code.  Unspecified is to be used after a preliminary diagnostic has been performed and the provider cannot determine at this time what type of neoplasm this will be on definitive work up.  They use terns like tumor to indicate a neoplasm unspecified.  Without some type of a workup the provider cannot know by visual inspection that this skin lesion is anything to be concerned about, which is why it is removed and sent to path.  For a biopsy or a shave removal you do not have to wait for path so the Dx code that the coder can use is the L98.9 for skin lesion.  For an excision the claim must be held and wait for path as the CPT codes are available for only benign or malignant status.  Just because a payer indicates that a certain Dx Code will pass medical necessity does not mean the coder may select one of those.


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