Coding Consult

November 5, 2004

Suspicious lesions?

You may not want to make the patient wait for a bill, but you have no choice: There's no CPT and ICD-9-CM combination that describes a "suspicious" skin lesion. CPT contains only benign and malignant lesion removal codes.

Suppose you remove a 2-mm suspicious skin lesion from a patient's back using a 1-mm margin. You have to choose between two procedural codes-11400 (excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) and 11600 (excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less).

Your patients may well question charging more for a malignancy, though. After all, you perform the same procedure regardless of the pathologist's findings. You may be able to explain a higher charge by telling them that it all evens out: A malignancy may contribute more to your bottom line, but the fact is, certain payers may not cover certain benign skin lesion removal at all.

Reporting a malignancy also justifies future follow-up services, explains Mary I. Falbo, president of Millennium Healthcare Consulting in Lansdale, PA. Therefore, it's best to hold the claim until a pathology report is provided. Furthermore, you won't know if you should charge the patient for the noncovered service until you know the lesion's type. This is another reason to hold the claim until a pathology report leads you to or confirms your CPT code selection.

In the above example of a suspicious back lesion, your diagnostic options include:

Could you use an uncertain behavior diagnosis and submit paperwork before getting the pathology report? You shouldn't initially diagnose uncertain behavior, says Falbo. A pathologist makes this determination based on analysis. If the pathologist determines that the neoplasm is of uncertain behavior, he may request a further resection to make a more definitive diagnosis.

The bottom line: Wait for the pathology report.

What if the path report is inconclusive? Even though uncertain and unspecified diagnoses don't apply to suspicious lesions, you should link 238.x and 239.x to your lesion excision claims when you file inconclusive pathology reports and precertifications.

You may report an uncertain behavior ICD-9-CM code (238.x, neoplasm of uncertain behavior of other and unspecified sites and tissues) when a pathologist requests additional samples. The original specimen may contain mutating cells that haven't yet developed malignant characteristics (that's uncertain behavior). The pathologist therefore requests additional samples to see whether subsequent cells are progressing malignantly.

If the pathologist's second report remains inconclusive, submit the excisions as benign (11400-11446, excision-benign lesions) with an uncertain behavior diagnosis code.