Dermatology Coding Alert

238.2 or 239.2? The answer lies in the details.

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.

Step 1: Highlight These Subtle Details

Using 238.2 (Neoplasm of uncertain behavior of the skin) and 239.2 (Neoplasm of unspecified nature of 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].”

“Uncertain” is used when the pathology report contains words such as “dysplastic,” “atypical,” or “unusual.” In addition, there are some neoplasms that may have a slight chance of becoming malignant at some date, such as congenital nevi or junctional nevi.

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. It also describes a lesion that has not been pathologically diagnosed, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. In these cases, no biopsy has been performed so no definitive diagnosis is available, she says.

Step 2: Be Aware of the Discrepancy

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.

Step 3: Wait for the Report

You should hold all charges until you get the pathology report and confirm the actual diagnosis for codes such as 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), 11101 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; each separate/additional lesion), 11300-11313 (Shaving of epidermal or dermal lesion…); 11400-11446 (Excision, benign lesion including margins…); and 11600-11646 (Excision, malignant lesion including margins…), experts say. 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.

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