Primary Care Coding Alert

Even though uncertain and unspecified diagnoses don't apply to suspicious lesions, you should link 238.x and 239.x to your lesion excision claims when you file inconclusive pathology reports and precertifications.

You may report an uncertain behavior ICD-9 code (238.x, Neoplasm of uncertain behavior of other and unspecified sites and tissues) when a pathologist requests additional samples. The original specimen may contain mutating cells that haven't yet developed malignant characteristics (uncertain behavior). The pathologist therefore requests additional samples to see whether subsequent cells are progressing malignantly.

If the pathologist's second report remains inconclusive, submit the excisions as benign (11400-11446, Excision -- benign lesions) with an uncertain behavior diagnosis code. "Billing uncertain behavior avoids tagging the patient with a condition he doesn't have," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, Pa.

Tip: You will rarely use an uncertain behavior diagnosis because pathologists don't often return uncertain behavior reports, Falbo says.

Lesion excision precertification may seem impossible if you don't have an ICD-9 code, but you can submit an unspecified diagnosis to increase your reimbursement odds.

Suppose a patient presents with a suspicious hand lesion. Prior to excision, you call the patient's insurer to precertify the surgery. The insurer requires a precertification diagnosis.

Solution: Because no pathology report is available, use 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin). After the family physician removes the lesion, the pathologist sends you a benign pathology report. Submit the surgery as 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less), assuming the excised diameter is 0.5 cm or less,with 216.6 (Benign neoplasm of skin; skin of upper limb, including shoulder).