Oncology & Hematology Coding Alert

Question: Benign lesion excisions are not covered by our state Medicaid. We have been losing payment as we confirm the benign nature of the lesion only after we get the histopathology report. Can you please suggest how we can ensure we earn for benign lesion excision.

Oregon Subscriber

Answer: Carrier policies exclude coverage of benign lesions, as they are considered cosmetic unless it is confirmed and documented as causing the patient pain or irritation necessitating removal. Therefore, the course of care should include a biopsy of the lesion prior to removal to determine the histological nature of the lesion cells. If the pathology confirms a benign lesion and the patient would like to proceed with removal, verify what specific waiver of liability process you must follow and the specific form or language needed meet the program’s notification requirements. The form may be similar to Medicare’s Advanced Beneficiary Notice (ABN), when you expect a denial or noncoverage for the service(s) requested, however Medicare’s ABN is not to be used for non-Medicare patients. The patient, by signing the document, would become responsible for the cost of the procedure.