Practice Management Alert

Hint: Wait for the path report to avoid payer scrutiny.

If you always use diagnosis code 238.2 (Neoplasm of uncertain behavior of skin) when you're reporting 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) for a biopsy procedure your physician performs, you're setting your practice up for disaster. The key to knowing when to use the "uncertain behavior" diagnosis code is understanding what that code descriptor really means. Follow these expert tips to ensure you're choosing the correct diagnosis code for all your 11100 claims.

Wait For Pathology Before Choosing a Code

When your physician performs a biopsy you should always wait until the pathology report comes back to choose the proper diagnosis and procedure codes to report -- even though this will not always affect the CPT code you will wind up choosing.

Reason: The biopsy specimen's pathology will affect the ICD-9 code you report, but most CPT procedure codes are not based on the specimen's results. "There are a few CPT codes which are linked to specific diagnoses (for instance, excision of benign and malignant lesions), but overall CPT is about what you did; ICD-9 is about the outcome or the reason for it," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Get to Know the Meaning Behind 'Uncertain' Codes

When you report 238.2 as the diagnosis for a biopsy procedure, you're telling the payer that the pathologist said in his path report that he was uncertain as to the morphology of the lesion, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

"Uncertain behavior doesn't mean that the coder is uncertain or that the physician thinks the lesion looks suspicious but it might be benign," Bucknam explains. "Uncertain behavior means that a specimen has been examined by a pathologists and that the cells are of mixed types."

How it works: Uncertain behavior diagnoses are appropriate for specimens identified as hyperplastic (hyperplasia) or precancerous. If you submit a claim with 238.2 as a diagnosis before you have the pathology report back, you may have actually told the insurer that the patient has a disease process that he doesn't actually have or may have but has not yet been confirmed, Bucknam explains.

"If you are not sure what a lesion is, you use unspecified, not uncertain," Cobuzzi explains. "Uncertain is reserved for a pathologist only diagnosis."

Example: Your physician sees an irregular lesion on patient's face. The color and shape bothers him and he suspects the lesion may be malignant, but does not want to fully remove it because of its size and location unless it is necessary. Therefore, he only takes a biopsy of the skin and subcutaneous tissue (11100) and sends the sample to pathology. On pathological evaluation the pathologist cannot determine if the cells from the lesion are malignant or benign, so, he assigns the diagnosis of "uncertain behavior." In this case, you would legitimately report 238.2 as the diagnosis code after receiving the pathology report, Cobuzzi says.

Caution: Some payers -- "which often do not really knowing the coding rules," Bucknam adds -- require you to use 238.2 for suspicious lesions. If your payer instructs you in writing to code this way, you should follow the instructions your payer has given.

Don't Rush Coding Just to Get Paid

You should never code just to ensure you'll be paid for a procedure. In the case of a biopsy, waiting to code until  you have the pathology report should not affect your reimbursement amount anyway. You may have to wait a bit longer to see the reimbursement if you need to hold a claim while you wait for the pathology report, but your coding will be much more accurate.

"If you biopsy a lesion and the results come back as precancerous this is exactly the diagnosis you would use so it is a perfectly payable diagnosis," Bucknam says. "On the other hand, insurers are looking for more and more reasons to deny payment. If you had performed a biopsy and indicated that the patient has hyperplasia and then the doctor found out that the biopsy indicated melanoma and the patient returned to have excision of the melanoma and the insurer ever compared the documentation there could be problems."

Additionally: If you report the service with 238.2 but the patient actually has a benign lesion you run the risk of having to repay the insurance company during an audit. Should the payer ever look closely at your physician's documentation, they could require repayment "based on the fact that the rules for coding and billing benign lesions are (often) quite different from the rules for billing for treatment of precancerous lesions" Bucknam warns. "They might feel that you were using the diagnosis of neoplasm of uncertain behavior in an effort to establish medical necessity for services that might otherwise be considered cosmetic."

"A payer could actually bring a practice up on charges (civil or criminal) for improperly coding the ICD-9 since that is what determines the 'medical necessity' for payment from the payer," Cobuzzi adds.

Bottom line: "I know that it delays billing and also can add complexity to wait for the path report but it is the correct way to code the services and in these uncertain times it is critical to follow the rules as closely as possible," Bucknam says.