# ICD-9 Help / Dysplastic Nevus Back



## Amanda Victoria Lewis

*Hello Fellow CPC's,
I am having an issue with the theory behind the coding of a dysplastic nevus of the" back", confirmed by pathology report. I know that a dysplastic nevus has characteristics of a malignant lesion, although it is really not considered malignant. So here is my issue. What code do I use 238.2 or 216.5? My only issue with 238.2 is if you look in the 2010 ICD-9 book under the tabular listing it says right under 238.2 "TIP: Assign this code for keratocanthoma only". That would make me lean towards the other code. Or is keratocanthoma the same thing as a dysplastic nevus (I don't really think so)? Do I ignore this tip in the tabular listing? I was taught that I should pay close attention to all the little notes in the tabular listing because it will help you choose the proper code. Plese help. Which code 238.2 or 216.5?
Thanks
Amanda Lewis*


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## vj_tiwari

Hey,

I think 216.5 is the one! 

A dysplastic nevus (also known as a: Atypical mole, Atypical nevus, B-K mole, Clark's nevus, Dysplastic melanocytic nevus, Nevus with architectural disorder[1]) is an atypical melanocytic nevus;[2] a mole whose appearance is different from that of common moles. Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. Their color frequently is not uniform and ranges from pink to dark brown; they usually are flat, but parts may be raised above the skin surface. Dysplastic nevi can be found anywhere, but are most common on the trunk in men, and on the calves in women.

Keratoacanthoma (ICD 9 CM code is 238.2) is a relatively common low-grade malignancy that originates in the pilosebaceous glands and closely resembles squamous cell carcinoma (SCC). In fact, strong arguments support classifying KA as a variant of invasive SCC. The pathologist often labels KA as "well- differentiated squamous cell carcinoma, keratoacanthoma variant". KA is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4–6 months in most cases. KA reportedly progresses, although rarely, to invasive or metastatic carcinoma; therefore, aggressive surgical treatment often is advocated. Whether these cases were SCC or KA, the reports highlight the difficulty of distinctly classifying individual cases.

And hey... paying attention to tabular list is really a good thing, so dont't avoid. Also when you are not coming to any specific code viz., cancer, neo. etc please refer to morphology of neoplasm in ICD 9CM.

Hope this helps! 

VJ.


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## Amanda Victoria Lewis

Thanks a million VJ. I appreciate your response. I was hoping someone would respond to my post. I would have chose the other code,but the tip in the tabular listing makes me skeptical.


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## jmastel

Check the neoplasm section:

Neoplasm, skin, back - uncertain behavior - 238.2

If you wish to use 216.5, 238.2 should be used as a secondary code
since you are billing from path report, and have a dysplastic diagnosis.

JAM


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## AB87

216.5 is the right code im a derm coder and if the Doc says r/o BCC SCC i would use 238.2 which is uncertain behavior.


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## mitchellde

randrk said:


> 216.5 is the right code im a derm coder and if the Doc says r/o BCC SCC i would use 238.2 which is uncertain behavior.



 sorry but you absolutely cannot code any condition documented as "rule out".  238.2 is not a dx code to use when the physician indicates uncertainty in the dx.  It is a dx code used when the pathologist indicates that the dx is a neoplasm of uncertain Behavior. it is a dx that can be rendered only after examination of cells under a microscope.


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## ERINM

We use 238.2 for Atypical Nevi-since there is no actual dx code our physician feels this is the best fit. Coding 216.xx doesn't show the medical necessity and would most likely be denied by insurance. Atypical Nevi should be removed and are considered medically necessary.


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## mitchellde

ERINM said:


> We use 238.2 for Atypical Nevi-since there is no actual dx code our physician feels this is the best fit. Coding 216.xx doesn't show the medical necessity and would most likely be denied by insurance. Atypical Nevi should be removed and are considered medically necessary.



The dx is the patient's not the physicians therefore you cannot use a dx that the patient does not have just to get a claim paid.  You will need to bill the 216.xx and then if it is denied as cosmetic you can appeal.


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## Amanda Victoria Lewis

Thanks I appreciate everyone's opinions. It helps me a lot.


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## amberpurdy

If the Dr is coding the procedure as a biopsy (11100) then you would not know what the diagnosis was and you would use 238.2 as your diagnosis code.

If you are coding it with the excision codes 11400 - 11406 then you would use the 216.5 diagnosis code.

If it turns out to be malignant then you would use the excision codes 11600-11606 and the diagnosis code would be 173.5 for Basal cell carcinoma and Squamous cell carcinoma, and 172.5 for Melanoma, if it is malignant in situ then the diagnosis would be 232.5

You don't code the excision codes until you have the diagnosis, they will not pay for the unknown diagnosis code 238.2.

Often my dermatologists will code the biopsy code for the original surgery and then  when they do the reexcision to remove the rest of the lesion they will code with the excision codes and by then we already know the diagnosis code and do not have to hold the claim while we wait for path.

Hope this helps,

Amber L. Newcomb
CPC
Dermatology


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## mitchellde

ambernewcomb said:


> If the Dr is coding the procedure as a biopsy (11100) then you would not know what the diagnosis was and you would use 238.2 as your diagnosis code.
> 
> If you are coding it with the excision codes 11400 - 11406 then you would use the 216.5 diagnosis code.
> 
> If it turns out to be malignant then you would use the excision codes 11600-11606 and the diagnosis code would be 173.5 for Basal cell carcinoma and Squamous cell carcinoma, and 172.5 for Melanoma, if it is malignant in situ then the diagnosis would be 232.5
> 
> You don't code the excision codes until you have the diagnosis, they will not pay for the unknown diagnosis code 238.2.
> 
> Often my dermatologists will code the biopsy code for the original surgery and then  when they do the reexcision to remove the rest of the lesion they will code with the excision codes and by then we already know the diagnosis code and do not have to hold the claim while we wait for path.
> 
> Hope this helps,
> 
> Amber L. Newcomb
> CPC
> Dermatology



Again 238.x codes are not to be used until you have a path report that states uncertain behavior.  The dx code is not for uncertain as to morphology, they are for uncertain BEHAVIOR morphology.  You do not use this dx code for a biopsy, unless you have waited for the path and that is the result, you can use a 709.x code for the biopsy.  If your physician does a full thickness removal of the entire visible lesion then it is not a biopsy it is an excision.  If path shows positive margins then you may code for the re-excision when the physician performs that and you do already have the path report.


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## muthershyp

When coding an excision, always wait for the pathology report otherwise how would you know whether to use a benign excision code or a malignant excision code.

283.2 falls into a catagory of neoplasms which have already been microscopically reviewed and are still uncertain.


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## preserene

I agree with Mitchellede in her saying "The dx code is not for uncertain as to morphology, they are for uncertain BEHAVIOR  with its morphology". Even there are many schools of thoughts and controversies about its behavior between Clinicians and Pathologist.
 I would like to state that
morphology does not always predict biological behavior any more than a biopsy
will always give a diagnosis.
In my openion, the clinician is obliged to re-excise, and explain to the patient that
microscopically it has features that appears to be "pre-malignant or starting
to become malignant" and that the site should be re-excised for maximum
safety.

There are degrees of
"benign", i.e. mild-to moderate-to-severe cytologic atypia, and that we
should re-excise moderate to severe atypia with adequate margins.  Its clear from this discussion that all this stuff 
about mild, moderate, and severe cellular atypia and mild, moderate, 
severe architectural atypia doesn't 
amount to anything except to detract from communication of whether 
something is benign, malignant, or "unsure". The responses as to what all of us are doing re: "nevi w/ architectural
disorder and 1)mild 2)moderate 3) severe melanocytice atypia has been
interesting, but since this is a relatively new categorization of nevi.
Are there "benign"melanomas, an addition to the spectrum of benign PL, dysplastic PL, MIS,
SSM, nodular MM, Met. MM? I do not know any answers to these issues but
they are certainly very important questions. It is unclear if future molecular diagnostics will help or obfuscate the answers.
As for us for our discussion, the "dysplasia' is a condition just a step away of the carsinoma in situ and its biological behavior is unpredictable .This is the bottom line of the interpretation of the all these terminology and let us leave the debate to doctors with unbiosed openion about its future behavior which is not in our hands especially unpredictable types of this dysplastic nature


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## m.edwards

239.2 can be a better code to use if you are billing for the biopsy prior to the pathology.
When its an excision, always wait for the pathology before billing.

In response to the comment of rule out codes...you can code a "rule out" diagnosis ONLY in an INPATIENT SETTING.


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## mitchellde

mfloit said:


> 239.2 can be a better code to use if you are billing for the biopsy prior to the pathology.
> When its an excision, always wait for the pathology before billing.
> 
> In response to the comment of rule out codes...you can code a "rule out" diagnosis ONLY in an INPATIENT SETTING.


Only if you are the inpatient facility coder not the physician coder.


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## valleycoder

i realize that this is an old post but when i see or hear a statment like "insurance wont pay for xxx.xx dx so we use xxx.xx", the compliance auditor in me is immediately activated and i cannot let this slip by without saying that if you are following that theory, you are putting the organization that you work for at a huge liability risk should you ever get audited.  You should never code to get something paid - you code the service as it is.  

Secondly, i'm not really sure why anyone is contemplating the use of 238.x.  If you look up nevus in the tabular, it distinctly says neoplasm/skin/benign, which doesnt crosswalk to 238.x 

And lastly, i want to echo Debra's response regarding coding a rule out for inpatient facility coders only.  Just because a patient is inpatient doesnt mean you can code rule outs for professional fees.  

i hope some of the comments in this posting are simple misspeaks.


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## KaitlynEFitch

You don't code the biopsy (11100) as a 238.2... you would wait for the biopsy results to come back and use the definitive diagnosis for everything that is ever sent off to a lab.


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## pboey

*Derm*

Thank you for sharing.. Great explanation!


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## CatchTheWind

From CPT Assistant August 2000, pages 5-6:

When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathological diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. 

Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646).

(I know that was 14 years ago, but I am not aware of any changes since then.)


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