Wiki Codes: 17000 & 17110

[danetta04]

I work at a dermatology office and we recently had an audit with BCBS. They are doing a special investigation on codes 17000 & 17110. They are requesting us to send in clinic note along with claim form if the patient received these services. . I am now receiving feedback on it and they are denying these codes for medical necessity. I reviewed the physician's notes and the patients are being treated for AKs (L57.0) with 17000 and ISKs (L82.0) or Warts with 17110. This is being stated in the notes as well as the location(s) of the lesions. They are denying for medical necessity. I am not sure what BCBS will need to process these particular codes for reimbursement. Does anyone have any suggestions?

 

[ellzeycoding]

AKs with 17000 are pretty much standard to be covered by nearly all carriers (without exception) with L57.0 using CPT 17000. Ask the carrier to show you their published policy for 17000 showing the medical necessity requirements for AKs.

For comparison, AKs are covered with L57.0 by Medicare without exception based on the National Coverage Determination policy NCD 250.4

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=238&NcaName=Allogeneic+Hematopoietic+Stem+Cell+Transplantation+(HSCT)+for+Myelodysplastic+Syndrome&ExpandComments=y&CommentPeriod=0&NCDId=129&ncdver=1&bc=AiAAAAAAIEAAAA%3D%3D&

In regard to destructions of other benign lesions such as SKs, there are often medical necessity requirements (itching, bleeding, painful, etc.) that should be documented. Medical necessity requirements vary from carrier to carrier.

Again, Medicare LCDs are published and easier to locate for a comparison. I'm not sure where you are located (what state), but here is an example of an LCD for Medicare contractor (again not BCBS), but it shows you w

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34233

Your best defense is to have them show you how/where to locate the published payment policy showing the medical necessity requirements.


AKs should be covered as they are premalignant and have a higher probability of turning into a cancerous lesion such as SCC.

Inflamed seborrheic keratoses (L82.0) are usually covered by themselves without exception because they are inflamed! The inflamed part is the medical necessity.

Lastly, you could also contact Faith McNicholas or Peggy Eiden at the American Academy of Dermatology coding division to see if they have any input. They have gotten the AAD involved in the past when a carrier becomes unreasonable or begins establishing policies that are outside of the accepted norm for the industry.

 

[danetta04]

Ok thank you so much for your help!