General Surgery Coding Alert

The info you need is in the pathology report, not necessarily encounter notes

When assigning a diagnosis for lesion removal, remember that you should wait and rely on the pathology report to choose the correct ICD-9, rather than refer to the surgeon's own note.

Consider this example of why this is important:

The procedure: Your surgeon documents, -I removed one approximately 9-mm lesion from the patient's wrist using surgical curettage. Lesion had a red outer crust and an irregular border, but it looked dissimilar from the patient's actinic keratosis spots on her face, so I am uncertain of the lesion's status. Sent lesion to the lab, and will await results.-

What not to do: In this case, based on the documentation, you might be tempted to assign a diagnosis of 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin) to this claim. But this is a mistake.

Here's why: -You can report 238.2 only if the pathologist who examines the sample states that the lesion exhibits uncertain behavior, not when the physician thinks it might be,- says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore. -It has to come from the histopathology. So unless the physician is looking at it under the microscope, that code has to be assigned from the pathologist.-

In fact, according to ICD-9, -uncertain behavior- means something totally different from what people think, Felthauser says.

Example: -Sometimes a physician will review a patient's lesion that is growing in size, or changing color or irritating a patient, and from looking at the lesion it is -uncertain- to the physician whether this lesion is benign or malignant, so he elects to remove it and send it to pathology for review,- Felthauser says. -But if the lesion has not yet been histologically assessed, you should not report 238.2.-

If you code this report, you should either wait for the pathology report to determine the correct ICD-9 code, report a diagnosis code based on the symptoms, or select an -unspecified- code such as 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin).

Tip: -If the lesion was irritated, bleeding or had other such features, make sure you have that information documented as well because most carriers do not cover -cosmetic- removals of benign skin neoplasms,- Felthauser says. -So you need to make sure there is documentation as to why he chose to remove it, and remember to code for those services.-