Orthopedic Coding Alert

Read the physician's documentation and put your diagnosis coding skills to the test

Now that you-re up-to-speed on choosing an ICD-9 code from the physician's notes, read the following sample documentation and determine whether you can put the correct diagnosis code on your physician's claim form: 

Documentation: -Just before I performed an SI injection, I discovered an approximately 9-mm lesion on the skin above the patient's hip. I removed the lesion 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.-

How did you fare? Most coders tell us that they would assign 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin) to this claim. But this is actually the wrong code for this physician's documentation.

-You can only code 238.2 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.

For 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 or not this lesion is benign or malignant, so he elects to remove it and send it to path 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 709.9 (Unspecified disorder of skin and subcutaneous tissue).

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.-