Dermatology Coding Alert

Waiting for the path report can provide you with a more specific diagnosis.

Do you know the difference between neoplasm codes 238.2 and 239.2? If you assume 239.2 is the right diagnosis for all non-malignant lesions, you could come face to face with a denial.

Don't end up in a compromising situation without first knowing which way you should go with these three guidelines.

Using 238.2 (Neoplasm of uncertain behavior of the skin) and 239.2 (Neoplasm of unspecified nature, bone, soft tissue and skin) is a familiar tune in dermatology. It's not unusual that you take one for the other since both codes refer to a lesion that is not certain in nature.

However, if you look closely at their definitions, you'll find that they have slight but very distinct differences.

Don't miss: Code 238.2 belongs to the family described as "neoplasms of uncertain behavior" (235-238), specifically "histomorphologically well-defined neoplasms, the subsequent behavior of which cannot be predicted from the present appearance," according to the ICD-9 book. This code refers to the skin and excludes "(1) anus NOS [not otherwise specified]; (2) skin of genital organs [236.3, 236.6]; and vermilion border of lip [235.1]."

On the other hand, 239.2 refers to neoplasms of unspecified morphology or nature of bone, soft tissue and skin, which excludes "(1) anal canal [239.0]; (2) anus [NOS 239.0]; (3) bone marrow [202.9]; (3) cartilage; (4) larynx [239.1]; (5) nose [239.1]; (6) connective tissue of breast [239.3]; skin of genital organs [239.5] and vermilion border of lip [239.0]."

Difference: Code "239.2 is a broader descriptor as it could describe a lesion of bone, soft tissue, or skin, whereas 238.2 is limited to skin lesions," says Brent Moody, MD, founder and medical director of Skin Cancer and Surgery Center in Nashville, Tennessee.

Many carriers have benign lesion policies that provide lists of covered diagnoses. The majority of such medical necessity policies include code 238.2 but not 239.2. This may be the reason why 238.2 is universally accepted among dermatologists and dermatopathologists.

The bottom line: The ICD-9 system is designed, published, and updated by the World Health Organization as a method for recording morbidity and mortality information for statistical purposes, indexing hospital records by disease category, and for storing and retrieving data. Although ICD-9 today mistakenly functions as such to many practitioners, it was not intended as a system for billing insurance carriers. It is the only diagnosis system that's available, so providers and carriers in the US have adopted this system for billing third-party payers.

Reality bites: Problems do exist, as shown by the discrepancy of using 238.2 and 239.2. Many dermatology diseases and conditions are either not classifiable or share the same ICD-9 code. Many still are difficult to assign with any appropriate code and end getting lumped into some "not otherwise specified" category.

If you want to charge the insurer before you have the path results, skin biopsy codes 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and 11101 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; each separate/additional lesion) are acceptable with 238.2. In other words, you can use 238.2 no matter what result you get for the histological diagnosis of the skin lesion.

Better idea: You should hold all charges until you get the pathology report and confirm the actual diagnosis for codes such as 11300-11313 (Shaving of lesions); 11400-11446 (Excision of benign lesions); and 11600-11646 (Excision of malignant lesions). Common sense dictates that you can't bill out the malignant excision codes when you don't have a malignant diagnosis.

If the lesion is histologically identified with a certain diagnosis, bill the specific ICD-9 code that reflects that diagnosis (as described in Example 1).

Example 1: If the lesion is identified as an inflamed seborrheic keratosis, bill 702.11 (Inflamed seborrheic keratosis) and not 238.2.

On the other hand, there are cases when the lesion is hard to diagnose even histologically. For instance, you won't find any specific ICD-9 code for dysplastic nevus. When you're unsure, you can bill either 238.2 or 216.x (depending on the site). The following example further illustrates it.

Example 2: If the lesion turns out to be an intradermal nevus of the trunk, assign code 216.5 (Benign neoplasm of skin; trunk) not 238.2.