Wiki Waiting for path before billing biopsy 11100

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rthames052006

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I was posed with a question that I am not sure of the answer to! I did review CPT assistant in search for an answer but nothing definate so here goes.

When billing for 11100 must you wait for the pathology to come back before billing out the dx? I know we are trained to do this when the provider is peforming an excision of a lesion because we need to know which family of codes to use benign or malignant.

I have a provider and a biller in disagreement, the provider says the biller doesn't have to hold all his biopsy claims for path report but the biller does.

Any takers...
 
I have no definitive-from-a-book answer for you, but logic says that we send out for biopsy we don't really know for sure what the specimen is. For this reason we use lesion of uncertain behavior for checking something out. The mal/ben excision codes get sent for biopsy, but the physician typically suspects malignancy or not because he/she is choosing to remove the entire skin problem rather than check it out with the 11100 biopsy. I do know a very prestigious dermatology biller uses the same method. Hope this helps. :)
 
Thanks Cher,

I do appreciate your insight. Sometimes I tend to "overthink" things and this was one of those times... I know of a place that holds everything until path comes back and I met a lady who is the Coding Manager who says they submit without a definative dx so not to run into untimely filing issues....

Thanks much!
 
cherramos said:
I have no definitive-from-a-book answer for you, but logic says that we send out for biopsy we don't really know for sure what the specimen is. For this reason we use lesion of uncertain behavior for checking something out. The mal/ben excision codes get sent for biopsy, but the physician typically suspects malignancy or not because he/she is choosing to remove the entire skin problem rather than check it out with the 11100 biopsy. I do know a very prestigious dermatology biller uses the same method. Hope this helps. :)
Click to expand...
You can code the biopsy without a path report but you cannot use the 238.x codes for uncertain behavior as that is a dx rendered by path. You can use skin disorder which is what an undiagnosed lesion is. Lesion of uncertain behavior is not a dx code for when the provider is uncertain about what the pat report will show, but rather a dx used by the pathologist when the cellular morphology is uncertain.
 
Not a problem... The excisions must be held for a path but the biopsy can be sent with a 709.x code. the one poster indicated sending an excision for biopsy which is incorrect language. you send an excision for path, and you send a biopsy for path. and excision and a biopsy are 2 types of specimen removals. By stating it incorrectly can cause issues with code selection.
 
Not according to coding clinics.. 239 neoplasm unspecified can be used only after a preliminary diagnostic study has been performed rendering a dx of a tumor. Since the skin lesion has only been looked at and then excised or biopsied then you have no preliminary study result indicating a tumor. for instance a patient that feels a lump under the skin, the provider may think it is a cyst or abcess and performs an I&D but there is no fluid, he states this is a tumor that requires further study, this then is coded with a 239 code since we now know this is not a cyst or abscess but is a tumor. A tumor is a neoplastic process that has yet to specified as either benign or malignant.
 
According to everything we've been taught, including information presented by Susan Ward, 239.2 is the correct diagnosis to use when a physician does a biopsy (11100) to obtain tissue for pathologic examination...."while it is recognized that some diagnoses resulting from a shave biopsy will at times be melanoma, the diagnosis at the time of the procedure was performed would most likely be 239.2, Neoplasm of unspecified nature; Bone, soft tissue, and skin, and this would be the appropriate code."

Thoughts?
 
The biopsy code 11100 should be billed with 238.2. because that is exactly why provider is doing the biopsy (trying to learn the nature of the lesion).
We do hold claims for the pathology repots because it can be very confusing for some patients to understand why they are getting two statements for same DOS.
 
AHA coding clinics are recognized as the authority on coding instructions and information I always defer to them. This is in numerous Coding clinics, refer to the codes in the code book for the coding clinic issue references. We code from provider documentation, he has not given any indication that this is a neoplastic process with unspecified cellular activity, he has described a skin disorder.
 
For years we were using 238.2, but after a lot of research and information from Susan Ward at the AAPC, correct coding states only use the 238.2 when you have a CONFIRMED pathology diagnosis. I.E. "238.2 is only to be used once a pathologic examination has been completed which has this diagnosis as its conclusion". (so dysplastic, atypical, etc.). Therefore, we now use 239.2... we have NEVER used 709.XX (skin disorder)!!
 
I will still maintain that the definition of the 239 does not match the physicians documentation and the physician statement is the only thing we are allowed to code from. The documentation will describe a skin disorder. The diagnosis belongs to the patient, it is inappropriate to assign a diagnosis not supported in the documentation. if the documentation describes a skin disorder then that is what you have you cannot step that up to a code of a higher severity. The aha coding clinics define the 239 as a working diagnosis to be used only after a preliminary diagnostic study has been performed indicating a condition yet unspecified by path. they go on to give the example of a tumor is a 239 dx as it is a neoplastic condition that has not had the benefit of pathology to determine the morhpology. I apolodize for disagreeing with Susan Ward, but I too have performed numerous hours of research and years of experience in cancer research in tumor registry as well as coding.
 
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