Primary Care Coding Alert

"

CPT, ICD-9 force you to withhold suspicious-lesion claims

Don't be tempted to bill claims for patients' suspicious skin lesions up front. You should instead defer coding until you receive the pathology report.

We wait for the pathology report to code any lesions that the family physician (FP) has suspicions about" " says Shari Aloway CPC coding specialist at Flowertown Family Physicians in Summerville S.C.

Why: Waiting for the pathology report allows you to select appropriate CPT and ICD-9 codes says Mary I. Falbo MBA CPC president of Millennium Healthcare Consulting in Landsdale Pa. Until the pathologist determines the skin lesion's nature you don't have enough information to choose either code.

However you may think making the patient wait for a bill or pay more if the skin lesion is malignant is inappropriate. But coding without a pathology report can prove an insurmountable feat.

If you still think you can code skin lesion excisions without a pathology report take this challenge: Find a CPT and ICD-9 combination that describes a "suspicious" skin lesion.

CPT Offers Benign or Malignant Categories

No suspicious or uncertain skin lesion excision code exists. CPT contains only benign and malignant lesion removal codes says Susan LeFevre CPC coder at the 10-FP Reedsburg Area Medical Center in Reedsburg Wis.

Suppose your FP removes a 2-mm suspicious skin lesion from a patient's back using a 1-mm margin. You have to choose between two procedural codes:
 

11400 - Excision benign lesion including margins except skin tag (unless listed elsewhere) trunk arms or legs; excised diameter 0.5 cm or less

11600 - Excision malignant lesion including margins trunk arms or legs; excised diameter 0.5 cm or less.

You could lose about $43 ($151.97 rather than $109.03 based on Medicare's geographically unadjusted rate) if you pre-emptively report a benign skin lesion code. "Reimbursement is higher for malignant lesions " Aloway says.

Problem: Your patients may question charging based on malignancy. "How can you justify billing a higher price for a cancerous lesion?" LeFevre asks. The FP performs the same procedure regardless of the pathologist's findings.

A malignancy may contribute more to your bottom line but you shouldn't code according to price. Reporting a malignancy justifies future services Falbo explains. And payers typically won't cover benign skin lesion removal. You won't know if you should charge the patient for the noncovered service until you know the lesion's type.

Solution: Hold the claim until a pathology report leads you to or confirms your CPT code selection.

'Suspicious'Doesn't Mean 'Uncertain ''Unspecified'

In the above suspicious-back-lesion example your diagnostic options include:
 

malignant such as 173.5 -- Other malignant neoplasm of skin; skin of trunk except scrotum

benign 216.5 -- Benign neoplasm of skin; skin of trunk except scrotum

uncertain behavior 238.2 -- Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin

unspecified 239.2 -- Neoplasms of unspecified nature; bone soft tissue and skin.

Jumping the gun and assigning a malignant neoplasm diagnosis based on your FP's suspicions would unnecessarily label the patient with a malignancy Aloway says. "Only the pathologist can determine a malignancy."

Could you use an uncertain behavior diagnosis? LeFevre asks. Under "Neoplasms of uncertain behavior " the Faye Brown ICD-9 coding handbook states "the ultimate behavior of certain neoplasms cannot be determined at the time they are discovered and a firm distinction between benign and malignant tumor cells cannot be made."

Watch out: You can't diagnose uncertain behavior. "A pathologist makes this determination based on analysis " Falbo says. You also shouldn't use an unspecified diagnosis because "unspecified" implies that your FP's documentation didn't indicate the skin lesion's type.

Bottom line: No CPT and ICD-9 combination describes a "suspicious" skin lesion. Appropriate coding requires you to wait for the pathology report.

"