Wiki Coding Basal Cell w/out Path

[judyhr]

Help!
I am new to Dermatology and the provider indicates his impression as basal cell carcinoma, however the patient has declined a biopsy to confirm dx. May I use the 173.xx or 709.9?

Thanks for any tips!

 

[mitchellde]

Help!
I am new to Dermatology and the provider indicates his impression as basal cell carcinoma, however the patient has declined a biopsy to confirm dx. May I use the 173.xx or 709.9?

Thanks for any tips!

Basal cell ca requires a path report. While the provider may feel that it has characteristics of basal cell it must be path proven before it can be documented and coded as such. The dx is the patients and if you do submit a claim as a basal cell and it is shown later that it is not, the payer has already assigned the high risk to the patient and it can cause an increase in their premiums.