# dysplastic nevus excision



## JesseL

Provider excised lesion on the back as if it were malignant so it was a wide excision.  pathology came back as dysplastic nevus.  would I code 238.2 with malignant excision code or benign excision code?


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## jorzano55@gmail.com

Hi you can not use a diagnosis that is not correct.  You can't bill malignant if it was benign that would be considered fraud and cost your doctor fines and possible losing his ability to participate with certain insurance companies.  Such as Medicare Medicaid.  It could also cause problems for the patient their plan could change or cause pre-existing issues.  A simple code error could cost the physician his license. And practice and you your job and certification.  Good luck.  Please read and review guidelines they are best tool to know forward and backwards.


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## teresabug

your provider has to hold his claims on excisions that are performed; wait for the path report to come back before you code these. If a path report states dysplastic you would use a code from the uncertain behavior column, etc...
malignant excision codes pay higher than benign ones so in essence your provider is "overcoding".


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## JesseL

the provider did a wide excision and the pathology came back as dysplastic nevus.  We did a wide excision because patient had a shave biopsy of the same lesion by another provider and it came back as atypical, but for us it came back as dysplastic nevus.  Patient has family history of melanoma also so the excision was medically necessary.

I also found this:http://downloads.cms.gov/medicare-c...ign_Skin_Lesions_Comm_Resp_art_pub_Nov_08.pdf

Question
When a lesion is removed that turns out to be a neoplasm of uncertain morphology (eg, melanoma vs
dysplastic nevi), is it correct to use excision of benign neoplasm rather than excision of malignant
neoplasm?
AMA Comment
"Uncertain behavior" identifies tissue that is beginning to exhibit neoplastic behavior but cannot yet be categorized as benign or malignant. Additional or further testing is required. To ensure correct coding, theremoval of the neoplasm should be coded after receiving the pathology report. When the morphology of a lesion is ambigous, *choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic 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). Thus, the CPT code that best describes the procedure as performed should be chosen


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## JesseL

JesseL said:


> the provider did a wide excision and the pathology came back as dysplastic nevus.  We did a wide excision because patient had a shave biopsy of the same lesion by another provider and it came back as atypical, but for us it came back as dysplastic nevus.  Patient has family history of melanoma also so the excision was medically necessary.
> 
> I also found this:http://downloads.cms.gov/medicare-c...ign_Skin_Lesions_Comm_Resp_art_pub_Nov_08.pdf
> 
> Question
> When a lesion is removed that turns out to be a neoplasm of uncertain morphology (eg, melanoma vs
> dysplastic nevi), is it correct to use excision of benign neoplasm rather than excision of malignant
> neoplasm?
> AMA Comment
> "Uncertain behavior" identifies tissue that is beginning to exhibit neoplastic behavior but cannot yet be categorized as benign or malignant. Additional or further testing is required. To ensure correct coding, theremoval of the neoplasm should be coded after receiving the pathology report. When the morphology of a lesion is ambigous, *choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic 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). Thus, the CPT code that best describes the procedure as performed should be chosen



So this is basically saying if a wide excision was done on a neoplasm of uncertain behavior/atypical/dysplastic nevus, then the malignant code should be coded since the lesion was cut out as if it were malignant which requires wider margins.

DOes anyone else find this to be true?


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## jorzano55@gmail.com

Ok you have been given advice from a few coders and the bottom line....you cannot code malignancy if benign.

You have gone a step beyond and gotten this info from AMA...You state shave biopsy was dysplastic Nevis and remote family history of something.  Patient previous dx non malignant and shave bx non malignant.

For whatever reason the doc and pt decided on wide excision but that still doesn't allow you to code for malignant.

I am sorry to be blunt but as a auditor and working with a major health insurance co and Medicare you are opening this claim up for a major audit and other possible legal issues.  It's one thing to argue a sinus infection vs a ear infection for instance but malignant when all proof shows benign is another.
Good luck.


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## JesseL

jorzano55@gmail.com said:


> Ok you have been given advice from a few coders and the bottom line....you cannot code malignancy if benign.
> 
> You have gone a step beyond and gotten this info from AMA...You state shave biopsy was dysplastic Nevis and remote family history of something.  Patient previous dx non malignant and shave bx non malignant.
> 
> For whatever reason the doc and pt decided on wide excision but that still doesn't allow you to code for malignant.
> 
> I am sorry to be blunt but as a auditor and working with a major health insurance co and Medicare you are opening this claim up for a major audit and other possible legal issues.  It's one thing to argue a sinus infection vs a ear infection for instance but malignant when all proof shows benign is another.
> Good luck.



You cant say a dysplatic nevus is benign... it's ambiguous, it can be benign or premalignant.  Studies show that patients with history of melanoma with dysplastic nevus are highly likely to develop into skin cancer, we didn't treat the lesion as if it were benign so we did the extra work to taking wider margins and deeper sections of the mole.  Since pathology didn't give a benign diagnosis then I feel that it should be coded as malignant excision since we treated it as if it were malignant due to the patients history.  The link I mention above, that seems to be from from CMS, states if the lesion is ambiguous then we should code base on how the growth was treated.  

Does anyone else agree to this?


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## jorzano55@gmail.com

Sorry I would like to make one more attempt at this

Could you send any quote or part of the pathology report?

Could you provide size of lesion you are coding for?

Could you describe wide excision, size dimensions, type of closure, how many layers closed and how?

What code did you use for procedure?  It's hard to go back to original post.

I want to help and I want to be sure info I give is accurate the info will help me help you.

Thanks


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## JesseL

I only need to know if I can bill as malignant excision if a dysplastic nevus or any ambiguous lesion is excised by wide excision in order to obtain clear margins.  We treated the lesion as if it were malignant and the pathology came back as dysplastic nevus which is neither benign or malignant because it has potential to be benign or turn into a melanoma...  That's all I need to know.  I'm not asking for how to code everything else.


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## jorzano55@gmail.com

Again you have a huge lack of respect for your fellow coders.  Your question has been answered more than once by more than one person.

You are beating a dead horse and someone takes the extra time to want to help and understand why protocols are not be followed by your doctor and yourself.

You know it all, so enjoy the wrath you are about to receive.


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## JesseL

jorzano55@gmail.com said:


> Again you have a huge lack of respect for your fellow coders.  Your question has been answered more than once by more than one person.
> 
> You are beating a dead horse and someone takes the extra time to want to help and understand why protocols are not be followed by your doctor and yourself.
> 
> You know it all, so enjoy the wrath you are about to receive.



Again I apologize for coming off rude.  But you are again asking questions that will not answer my question.  I am not asking how to code a lesion removal based on size and location and your questions reflects to that.  You claim that I am not following protocols, I wouldn't be here asking questions if I wasn't trying to, undercoding is just as bad as overcoding.  You say I'm beating a dead horse, well you're asserting that a dysplastic nevus  is benign when it is not benign nor malignant, its a lesion of uncertain behavior because it can go both ways.  A dermatologist would never advise a patient with a pathology result of dysplastic nevus as "benign" as there are risk factors of malignancy especially when the patient has a family history of melanoma.

Here I found a different answer that relates to my questions from mitchelleD, https://www.aapc.com/memberarea/forums/showthread.php?t=78537.  Who has always made educated responses from what I can tell and that makes more sense.  Her answer is completely contradicting to what you're telling me, where she states:

"if you look it up, "atypia" is another way of stating uncertain behavior (238.xx).
An old CPT assistant from many years back instructed that if the path indicated uncertain then you code the following:
If the excision was narrow (small margins) then code as a benign excision CPT with the 238.x dx code
If the excision was wide (lg margins or "wide local excision") then code as malignant excision CPT with 238.x dx code"

So I am not "beating a dead horse," this is a subject that I have found contradictory information and have yet to find a final answer.  The original link I posted with the response from the AMA also supports Debra's statement.  So it really comes down to if majority of coders follows this logic.  I can see you strongly disagree  but I'm sorry to say, asking questions that I didn't originally ask to answer my question does not help, where my original questions stated that the provider performed a wide excision and pathology came back as "dysplastic nevus" which is basically an uncertain diagnosis, and I inquired whether I should code this as malignant or benign since this lesion was approached as if it were malignant and pathology was abnormal.  In response   I don't understand why you would ask how big was the lesion or where was the lesion because that doesn't really make a difference  as to whether or not I should bill this situation as benign or malignant.


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## mitchellde

JesseL said:


> Again I apologize for coming off rude.  But you are again asking questions that will not answer my question.  I am not asking how to code a lesion removal based on size and location and your questions reflects to that.  You claim that I am not following protocols, I wouldn't be here asking questions if I wasn't trying to, undercoding is just as bad as overcoding.  You say I'm beating a dead horse, well you're asserting that a dysplastic nevus  is benign when it is not benign nor malignant, its a lesion of uncertain behavior because it can go both ways.  A dermatologist would never advise a patient with a pathology result of dysplastic nevus as "benign" as there are risk factors of malignancy especially when the patient has a family history of melanoma.
> 
> Here I found a different answer that relates to my questions from mitchelleD, https://www.aapc.com/memberarea/forums/showthread.php?t=78537.  Who has always made educated responses from what I can tell and that makes more sense.  Her answer is completely contradicting to what you're telling me, where she states:
> 
> "if you look it up, "atypia" is another way of stating uncertain behavior (238.xx).
> An old CPT assistant from many years back instructed that if the path indicated uncertain then you code the following:
> If the excision was narrow (small margins) then code as a benign excision CPT with the 238.x dx code
> If the excision was wide (lg margins or "wide local excision") then code as malignant excision CPT with 238.x dx code"
> 
> So I am not "beating a dead horse," this is a subject that I have found contradictory information and have yet to find a final answer.  The original link I posted with the response from the AMA also supports Debra's statement.  So it really comes down to if majority of coders follows this logic.  I can see you strongly disagree  but I'm sorry to say, asking questions that I didn't originally ask to answer my question does not help, where my original questions stated that the provider performed a wide excision and pathology came back as "dysplastic nevus" which is basically an uncertain diagnosis, and I inquired whether I should code this as malignant or benign since this lesion was approached as if it were malignant and pathology was abnormal.  In response   I don't understand why you would ask how big was the lesion or where was the lesion because that doesn't really make a difference  as to whether or not I should bill this situation as benign or malignant.


I am not sure where the issue has come on this, however,  a dysplastic nevi is not coded as benign.  It is by definition a neoplasm of uncertain behavior.  Since the excision codes are only for benign or malignant there needed to be some rule of thumb if you will.  Therefore the AMA did state that you go by the size of the margins,  which I guess you could say goes with intent.  The provider truely thought this possessed malignant properties and performed a wide excision.  The pathology which you did wait for came back with an uncertain morphology, therefore you code the excision using a malignant excision code.
You will encounter no wrath or fines or penalties doing this in this manner.  Any auditor will know this, and if they do not then you have all the authoritative info you need to back up your coding.


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## mitchellde

jorzano55@gmail.com said:


> Ok you have been given advice from a few coders and the bottom line....you cannot code malignancy if benign.
> 
> You have gone a step beyond and gotten this info from AMA...You state shave biopsy was dysplastic Nevis and remote family history of something.  Patient previous dx non malignant and shave bx non malignant.
> 
> For whatever reason the doc and pt decided on wide excision but that still doesn't allow you to code for malignant.
> 
> I am sorry to be blunt but as a auditor and working with a major health insurance co and Medicare you are opening this claim up for a major audit and other possible legal issues.  It's one thing to argue a sinus infection vs a ear infection for instance but malignant when all proof shows benign is another.
> Good luck.


The poster did not say the patient had a previous dx as non malignant with shave bx as non malignant.  She stated that the patient had a biopsy from a previous physician that was atypical.  This is not the same as benign.  Atypical is another way of saying uncertain behavior.  The posters physician then performed an excision and based on the biopsy of atypical and family history of melanoma he performed a wide excision in anticipation of a malignant path.  However the path came back as dysplastic nevus which again is not benign nor is it malignant it is uncertain behavior.  Per the AMA a wide excision with uncertain behavior pathology is coded as a malignant excision.  
If this is audited there will be no problem, if the auditor is uninformed, then the coder should have all of their authoritative references available to back up the coding.  This poster has performed her homework, she has the AMA reference and she knows dysplastic nevus is uncertain behavior.


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## JesseL

mitchellde said:


> I am not sure where the issue has come on this, however,  a dysplastic nevi is not coded as benign.  It is by definition a neoplasm of uncertain behavior.  Since the excision codes are only for benign or malignant there needed to be some rule of thumb if you will.  Therefore the AMA did state that you go by the size of the margins,  which I guess you could say goes with intent.  The provider truely thought this possessed malignant properties and performed a wide excision.  The pathology which you did wait for came back with an uncertain morphology, therefore you code the excision using a malignant excision code.
> You will encounter no wrath or fines or penalties doing this in this manner.  Any auditor will know this, and if they do not then you have all the authoritative info you need to back up your coding.



Thanks debra ,


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