Practice Management Alert

Question: Our practice is very confused about a recent LCD from NGS about how they want us to file claims for lesion excisions when the surgeon doesn't know the exact nature (benign or malignant) prior to the excision and pathology report. I've heard the payer is going to retract the LCD. Is that true?

Kentucky Subscriber

Answer: You are correct on both parts. Practices have been asking questions about the recent local coverage determination (LCD) from National Government Services (NGS) on lesion excision coding. But don't fret: NGS plans to rescind the LCD advice about lesion excisions. The portion of the NGS LCD that has led to controversy is in the general information section toward the bottom of the LCD. That section reads: "While it is recognized that some diagnoses resulting from an excision will at times be malignant, the diagnosis at the time the procedure was performed would most likely be 239.2 (Neoplasms of unspecified nature, bone, soft tissue, and skin), and this would be the appropriate code, since proper coding requires the highest level of diagnosis known at the time the procedure was performed. Medical records maintained by the physician must clearly document the medical necessity for the lesion removal(s) if Medicare is billed for the service ... The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis."

The issue: This advice goes against 2009 ICD-9 coding guidelines, which state: "For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive."

NGS is planning to print an article soon that will clarify this issue, according to NGS's medical director. That article will read: "Due to inconsistent and differing interpretations of coding instructions regarding this issue, the paragraphs pertaining to coding for excision of benign vs. malignant skin lesions are being removed from the SIA attached to the LCD for removal of benign skin lesions (L27362/A47397.) Providers are encouraged to code according to the coding instructions applicable to their various practice situations. NGS will not make an effort to make this coding more uniform and consistent at this time."

Bottom line: Despite the confusion generated by the NGS LCD, you should follow ICD guidelines and wait for the pathology report to determine if the lesion was benign or malignant when you're choosing a code to bill for a lesion excision.

-- The answers to the Reader Questions and You Be the Billing Expert were provided or reviewed by 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.