Oncology & Hematology Coding Alert

Medical necessity: If the ordering physician documents that the skin lesion demonstrates condition(s) such as bleeding, pain, itching, inflammation, oozing, or rapid growth or changes, you should report the appropriate symptom(s) to indicate that the provider performed the procedure due to a circumstance that may justify the lesion removal as not being for a cosmetic purpose. Also, if the documentation includes information of the mole interfering with daily functions, such as obstructing vision or breathing, Medicare should consider coverage for its removal.

ABN: Without medical necessity supported, you should be able to get paid for your work if you have a signed advance beneficiary notification (ABN) for Medicare or a third-party waiver of liability on file. The ABN or waiver form must be on file before the procedure occurs, because it allows the patient to refuse the procedure or be made aware they could be responsible for payment if coverage is denied. Remember, you should use ABNs in circumstances where there is reason to believe Medicare will not consider a service to be reasonable and necessary. They should not be employed on a routine basis.

Modifier: If you have a signed ABN for the anticipated Medicare denial, you should list a procedure code from 11400-11471 (Excision, benign lesion including margins, except skin tag …), more specifically 11440-11446 for a benign lesion located on the face, with modifier GA (Waiver of liability statement issued as required by payer policy, individual case). Without a signed ABN, you should use modifier GZ (Item or service expected to be denied as not reasonable and necessary), which means you cannot bill the patient for the service.

Stay current: If you are going to use an ABN, make sure you use Medicare’s latest version. Find the form and instructions for filling it out by going here.