Wiki D22 vs D23

[LBernat7]

Can someone please explain from a coding standpoint what the difference of D22's Melanocytic nevi and D23 OTHER Benign Neoplasm? For years anything that was a Dysplastic Nevus or Meanocytic or Beckers or Blue etc was all coded together. ICD-10 these appear to still fall under D22 codes. D22 is not being paid for shaves or excisions by Medicare (In this office patient 99% of the time has a BX or portion of spot to confirm DX then a must see for the shave or excisions is scheduled-Our Drs do not excise without confirmation of path) If our pathology lab used D23... on the path then everything would match to send to insurance, I bring up the matching thing cause so many insurance are denying claims off the bat and asking for notes (Specifically medicare and united health) Should we hae our drs talk to the lab on the way they are coding? Otherwise Medicare wont pay for the people whose DX is D22 anything

 

[ellzeycoding]

Melanocytic nevi are what we would traditionally call "moles". Dark colored splotches on your skin with well-defined boarders, etc. that aren't typical of other dark patch conditions like birthmarks or worse conditions like malignant melanoma,. These fall in to the D22 series and have their own ICD-10 series. D22 series is specific for the typical "mole" codes

The D23 or "Other benign neoplasms" is a "catch all" for all of the other conditions that don't have a specific ICD-10 series.

I have over 277 synonyms and cross-refrenced diagnoses in our DermCoder tool. You will notice that nevus or nevi aren't in this series. They fall into D22.

I've attached the list of synonyms to this reply.

So, if your lab is coding what your provider considers to be moles in the D22 series, they are correct.

I know I'm going around and around with you on several threads about this. The problem is your Pennsylvania Medicare carrier's LCD doesn't allow all many of the moles to be removed as benign lesions. In my professional opinion, this is a deficiency in their policy. You could campaign with their medical director to get them added to their LCD, or get the American Academy of Dermatology involved. PA's LCD is missing a LOT of the D22 series as covered diagnoses that most other carriers typically cover. You can try and change it!

Having the lab "Change" diagnoses for payment purposes would be considered F-R-A-U-D. Unless they are coding incorrectly. From what you are saying, they are not.

I understand where your office is coming from. The doctor considers them medically necessary to remove. He is probably right. However, some of the mole codes (like the ones on the trunk), your carrier doesn't consider medically necessary. Perhaps you can change it for the benefit of your practice and others in the state of PA.

Your carrier DOES cover some of the D22 series, only the face ones, though.

I am going to guess that they don't consider regular moles of the trunk to be considered medically necessary because they are generally not sun-exposed areas, such as moles on the face. Just a hunch. But I still think they are wrong.

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34938

This would be similar to MOHS being covereed for BCCs only on certain areas (like the face) for some carriers.

 

[ellzeycoding]

So here's a solution...

You say you biopsy them first, and know the diagnosis. At that point, your office can determine if the lesion will be covered or paid under the carrier's policy based on the diagnosis. If not a covered DX, you can have the patient sign an ABN stating you will try and get it paid, but if the carrier considers it medically unnecessary, THEY will be responsible for payment.

OR... skip the biopsy and do the excision and repair because the doctor is concerned about it (neoplasm of unspecified behavior) and bill the benign exicsion and repair with D49.2 (or D48.5). EITHER of those codes alone JUSTIFY medical necessity in the opinion of the carrier (per their LCD) and you can bill the benign excision without path.

You "could" wait for path results after excision, and if malignant, of course, bill the malignant codes. The malignant exicision codes require path confirmation, the benign do not.

Per the LCD...

"The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician or non-physician practitioner’s uncertainty as to the final clinical diagnosis."

So in otherwords, suspicion alone is enough to justify removing it.

BUT, since you are doing biopsy and path FIRST and know it's not a covered diagnosis, you can't bill this carrier for ICD-10 codes they don't consider medically necessary...

... unless you get them to improve their LCD!