Dermatology Coding Alert

Question: When a provider performs a lesion excision or a biopsy and does not know specifically at the time of the procedure what the actual diagnosis is, should I code the service with 238.2 or 239.2?

Florida Subscriber

Answer: You should use 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin). You should not report 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin) unless you have a statement on a pathology report to justify this report. Ideally, a coder should wait for the pathology report to be returned prior to coding the lesion excision.

Since you must match your excision code (malignant or benign) with an appropriate diagnosis, you should consider waiting for the pathology report. If you use a benign diagnosis code with a malignant lesion excision procedure code, you won't get paid.

-- Answers to You Be the Coder and Reader Questions were reviewed by Linda Howrey, BS, CCS-P, Howrey and Associates in Princeton, Mass.