Wiki 11100 & 69100 together

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michelledeaton@yahoo.com

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Pt had 1 biopsy to temple and another biopsy to the ear. Billed 99203, 11100 and also 69100. Using 238.2 dx codes. Insurance paid all but the 11100. Upon calling insurance I am informed that 11100 is not seperatly payable. Can anyone tell me what the issue could be with this coding combination?

I verified in my coding software and it shows no modifiers and no reason for denial.

Any advice would be greatly appreciated. THX
 
You'll need a modifier of 59 on the 11100. It isn't listed in my CCI edit book, but UHC and Medicare won't pay without it.

Modifer 59 Info "This
may represent a different session or patient encounter,
different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or
separate injury (or area of injury in extensive injuries)
not ordinarily encountered or performed on the same day by
the same physician."

I think it is because they are both biopsy codes, they want a modifier to tell them they were on different sites (even though you'd think the different code would do that).
 
michelledeaton@yahoo.com said:
Pt had 1 biopsy to temple and another biopsy to the ear. Billed 99203, 11100 and also 69100. Using 238.2 dx codes. Insurance paid all but the 11100. Upon calling insurance I am informed that 11100 is not seperatly payable. Can anyone tell me what the issue could be with this coding combination?

I verified in my coding software and it shows no modifiers and no reason for denial.

Any advice would be greatly appreciated. THX
Click to expand...
Yes you do need the 59 modifier, also if you do not have a path report you cannot use the 238.2 dx code. That code is for a confirmed path result of a neoplasm that is neither benign or malignant.
 
Debra is right, we will assume the pathology report states "Uncertain Behavior and your 238.2 that was reported is correct. But if the pathology report was not reviewed prior to charges being reported, use the Unspecified 239.2 for neoplasm(s) of the skin if the procedure note does not specify whether it is benign or malignant.
 
OCD_coder said:
Debra is right, we will assume the pathology report states "Uncertain Behavior and your 238.2 that was reported is correct. But if the pathology report was not reviewed prior to charges being reported, use the Unspecified 239.2 for neoplasm(s) of the skin if the procedure note does not specify whether it is benign or malignant.
Click to expand...
If you read the definition in the code book for the 239 codes it states that unless otherwise indicated the term "mass" (meaning all other words like mass including lesion, lump or bump) is not to be regarded as a neoplastic process. Once a preliminary diagnostic study has been performed and the provider renders a diagnosis or say tumor or abnormal growth then you may use a 239 code as a "working diagnosis". You can eith wait for the path or use the symptom as described in the note such as a 709 code.
 
while 238.2 is an acceptable code for these procedures it cannot be assigned without a path report. Please check the definition of the codes in the code book for those that disagree.
 
Thank you

I was thinking the same thing about the modifier, even though, like was mentioned, you would think the fact that these are on 2 seperate sites ( 2 different codes) the modifier wouldn't be needed.

BTW, I do have the pathology report. ;)

Thank you everyone for your input!!!
 
Using 238.2 without path

RE: "If you do not have a path report you cannot use the 238.2 dx code. That code is for a confirmed path result of a neoplasm that is neither benign or malignant."

Per the AAD (personal communication I had with their coding expert): "there are groups that say you need to wait for path [but] this code [238.2] has been reported for years [without waiting for path] and it works."
 
CatchTheWind said:
RE: "If you do not have a path report you cannot use the 238.2 dx code. That code is for a confirmed path result of a neoplasm that is neither benign or malignant."

Per the AAD (personal communication I had with their coding expert): "there are groups that say you need to wait for path [but] this code [238.2] has been reported for years [without waiting for path] and it works."
Click to expand...

Yes it works as the payer does not know you do not have the path. The definition of the code is in the code book and you cannot change the definition. These are patient diagnosis per the WHO which is the entity that created the codes and owns the copyright. The ICD-9 book states that these identify by site certain well defined histomorphopathologic neoplasms. That is a word that means after examination under a microscope.
Diagnosis codes belong to the patient not just as a means to a paid claim. When you assign this code you are giving the impression of a high risk dx.
Just because it has been done and it gets paid cannot be used as an excuse that it is correctly coded.
So once again let me state it is absolutely incorrect to assign a dx of 238.2 without the benefit of pathology.
 
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