Wiki Guidelines for no residual malignancy

[sinman0531]

We have had a recent influx of denials for inappropriate billing for this exact scenario:

-Provider takes shave biopsy and pathology comes back as malignant (specifically SCC).
-Provider schedules follow-up excision to confirm clean margins.
-Claim for follow up excision is denied as inappropriate because we are billing malignant codes, even though the pathology is coming back as no residual malignancy/clean margins.


All of the articles in coding magazines and blogs I have found confirm that if the excision is to confirm clean margins, then we are supposed to bill the malignant codes, even if the path comes back clean. However, for the life of me I cannot find an NCCI guideline or CMS guideline that says that. Does anyone have any idea where I can find one?

 

[thomas7331]

I would agree with you, if there was a known malignancy prior to the procedure, it's appropriate to bill that even if the pathology comes back negative, because the malignancy was the reason for the procedure.

What kind of denial are you getting for these? If you're billing malignant codes, how does the payer know that the pathology is negative unless they are requesting records and reviewing them? Their system shouldn't be denying them unless there's a problem in the way the bills are being submitted because the claims data doesn't show the pathology results. If a payer is denying claims, then they should be able to point you to some kind of written policy explaining the denial and instructing you on how they expect the claims to be submitted.

 

[sinman0531]

The denials are usually generic; “billing errors” or “not supported”.

Yes, they are requesting medical records, and the pathology that is done to confirm the clean margins is being sent, which is why they are denying it (since the pathology shows no malignancy), essentially ignoring the procedure notes where it specifically says they are excising the area to confirm clean margins.

We can send the previous path report separately, but I need some sort of official guideline to reference in the appeal.

 

[thomas7331]

The denials are usually generic; “billing errors” or “not supported”.

Yes, they are requesting medical records, and the pathology that is done to confirm the clean margins is being sent, which is why they are denying it (since the pathology shows no malignancy), essentially ignoring the procedure notes where it specifically says they are excising the area to confirm clean margins.

We can send the previous path report separately, but I need some sort of official guideline to reference in the appeal.

I definitely would be including the previous pathology report whenever records are requested - without that, your code if of course not going to be supported.

For an appeal, I think your payer needs to show you what guidelines they are following. Appealing without knowing what your payer's policy says is a bit like taking a shot in the dark. And if they're ignoring the content of the records in your appeals, that's something you'll need to escalate.

 

[thomas7331]

The denials are usually generic; “billing errors” or “not supported”.

Yes, they are requesting medical records, and the pathology that is done to confirm the clean margins is being sent, which is why they are denying it (since the pathology shows no malignancy), essentially ignoring the procedure notes where it specifically says they are excising the area to confirm clean margins.

We can send the previous path report separately, but I need some sort of official guideline to reference in the appeal.

There's some guidance in CPT Assistant from May 2012 that states that the CPT code should reflect the manner of the excision and not the final pathology report - this might be helpful in an appeal:

When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that best describes the procedure as performed should be chosen.

 

[sinman0531]

There is no policy—they’re using the fact that the pathology report for the same DOS as the excision shows no malignancy, so they’re saying it’s being billed incorrectly.

Since you generally can’t use previous documentation to support your current claim, we need to have some sort of guideline to back up the fact that we are sending a biopsy that was dated over 30 days before the claim in question. Obviously the provider narrative/procedure report isn’t cutting it.

I’ve seen the CPT Assistant, and it says that it’s guidance is from CMS….but where is that guidance? What LCD/NCD? I can’t find anything.

 

[thomas7331]

There is no policy—they’re using the fact that the pathology report for the same DOS as the excision shows no malignancy, so they’re saying it’s being billed incorrectly.

Since you generally can’t use previous documentation to support your current claim, we need to have some sort of guideline to back up the fact that we are sending a biopsy that was dated over 30 days before the claim in question. Obviously the provider narrative/procedure report isn’t cutting it.

I’ve seen the CPT Assistant, and it says that it’s guidance is from CMS….but where is that guidance? What LCD/NCD? I can’t find anything.

Actually I think it says the guidance is from AMA, not CMS. Either way, if you're dealing with a commercial payer, they won't necessarily recognize that guidance.

If the payer isn't cooperating - isn't reading the documentation you're sending and isn't able to give you a policy that they are following - then I would escalate the issue with a network representative. Just my opinion here, but I think you're into the territory of a payer dispute here, and more or better appeals isn't likely to change things. When submitting records becomes ineffective, then you generally need to try a different approach.