Home Forums Discussions Coding and Billing Coding a diagnosis for skin procedures

For any of you to do skin surgery, what do you choose for an ICD 9 code when completing the note and you do not have your pathology report back when you are doing the note? Right now, I am not using AC for billing purposes, but still print out a statement to attach to my other super bill. I am using the benign skin lesion codes, when the lesion may well be malignant. Should I be worrying about this or not? We do not do the final billing until we have the pathology report. The only other option I see is waiting to complete the note until you have the pathology report, unless there is an ICD 9 code that I am not aware of that I can use instead that would be appropriate

how about ICD-9 238.2 "Neoplasm of uncertain behavior of skin"?

I had thought about that as well, but I think that it is actually a specific diagnosis used by pathologists, so I do not think we can get away with using it. I read something about that a while back on some coding forum. Obviously, they did not say what code to use.

Mel,
I don't know the answer, but I am curious about how this relates to what I do. If I remove a polyp while doing an endoscopic procedure, I am not certain if the lesion is benign or malignant. I use the CPT code for a polyp removal, and the ICD-9 is for "colon polyp". If I had to wait for the pathology report to come back to do my billing, that would be a significant handicap. Is your situation the same? Do you get paid more for the same CPT if the diagnosis is a malignancy vs. a benign lesion? If not, then why not find a more generic code for a lesion (like Chris suggests) and use that?

Jon,
As for the initial biopsy, I think that it would usually not matter. For an actual surgery to remove the cancer, there is a tremendous difference in the amount of reimbursement. Before I used Amazing Charts, I would wait for the path report to come back on the biopsy and then bill accordingly. I still do that but AC forces me to enter a diagnosis to finish the chart entry or at least that is what I understand, being a relatively new user. I am uncomfortable with entering a diagnosis code into an electronic data base if it may not be correct. Maybe I am paranoid, but it must be stored somewhere in AC forever. This does raise the question about the billing side of the software and how that all works. Our office uses Lytec for billing, but I use the data entered for AC patient visits to create a statement that I give to the billing clerk, as it has all the information and codes, which is very handy. I also just had the idea that I should call the local dermatologist's office and ask them what they do. I wonder if you are missing a billing opportunity in not charging for removal of malignant polyps. We will have to check the CPT.

As an office doc who does not do biopsies or surgery, it's amazing to hear that insurance pays differently for removing benign vs. malignant lesions. IMHO, this further illustrates the inane system that physicians have to use to get paid! Why would you do a different initial procedure, not knowing yet whether the lesion was benign or not?

Let me know when the lynch mob forms up for the AMA RBRVS committee.

I always use 938.2 "neoplasm of uncertain behavior..." for the biopsy, and I don't think there is any problem with insurance companies accepting it.
If the biopsy turns out to be malignant, I usually send the patient to a surgeon for re-excision if necessary, and they get the big bucks.
If I do the re-excision myself, we charge a second fee.
It would be rare -- at least in my practice -- to do a large excision without a prior biopsy, and with the expectation that the lesion would be malignant, but if we do, we have to wait until the pathology report confirms it before billing.

Yes, a very crazy system.
But not likely to change any time soon given inertia and entrenched interests.
More likely a complete collapse is in store for us.

John,
For clarification, most of the time I will do a punch biopsy first to make the diagnosis and then excise the lesion, if warranted. The initial question was how to bill the diagnosis code. Sometimes, in the course of the punch biopsy, one will remove the entire lesion and it will turn out to be malignant. Sometimes, based on experience and the appearance, you will know the lesion is malignant and just remove it without a biopsy first. The reason that you get paid more for the definitive surgery is because of the calculated risk based on the diagnosis and management, how ever that is figured out. It must have had something to do with the initial RVU that the surgeons came up with. As we see with other parts of medicine, procedures pay more than our critical thinking skills. In this day and age, with the cost of our overhead, any procedures we can do in the office, presuming that we are independent and not employed, add to the bottom line. If I was trying to make it on just doing office visits and an occasional EKG, it would be difficult. The difference in RVUs is amazing. You can get paid more to remove a cerumen impaction from a Medicare patient's ear canals than you can to manage their diabetes, hyperlipidemia and hypertension and write all the prescripitons at the visit.

This illustrates some of the inequities in the current system. The entire RVU system was designed around procedures. My take is that it is specialist driven, since specialists are the ones generally doing procedures. Of course, I am biased, since I am a PCP.

We get the health care we pay for. Lots of people in specialty care, not enough in primary care and twice as much money going toward specialty vs primary care.

Another reason I love the AMA.

Funny how specialists say the opposite (or at least my dad says that) Sounds like all physicians are getting screwed. Fees are going up, but none of that money going to the physician.

Doctors can't unionize, but everyone is aiming at them. Insurance companies, hospitals, the government, etc.

The RVU scale started out as the "California Relative Value Scale (CRVS) and it was a handy book to have, back in the day when every doctor set his or her own fees. That was before "accepting assignment" and all the other dreadful banes of our "insurance" system.

However, for a few years in the early 1980's it was declared by the Feds to be "restraint of trade" if a doctor made reference to the book, and it disappeared from view -- everyone kept a secret copy, but they stopped publishing it.

Then along came Medicare with DRG's and the whole E&M scam based on "RVU's" -- in turn, based on guess what -- the CRVS!!

Go figure.

Tom

If biopsy: 238.2
If excision: Hold for biopsy report, then bill accordingly
Dave

Sure is the Specialist and the AMA by in large... There are a few docs who share a practice and point of view who have finally found a way to take the AMA and CMS to court over the inherent bias of the RUC commitee which sets the fees... I need to get home but google it and you'll find a ton of stuff on this.

Basically the AMA's RUC which at best should petition and advise the gov't has its "suggestions" approved at a rate of about 94-96% which is incredibly biased towards procedures and surgery. The RUC itself is a 27 chair commitee with only 4 docs on it representing the primaries with all the other chairs seated by you guessed it the entire rest of the better paid, for the most part procedure based specialties.... Of course they'll give us 10-20% on their obligitory Office Visits in exchange for a similar increase in their expensive knock out a batch each day procedures and surgeries... 10% of $100 is a heck of a lot less than 10% of $1,000 bucks now wouldn't ya say????

This is a board that is essence has become a governmental regulating and policy setting agency that meets in the dark, we the public in general have NO Access to their records or meetings, no means of addressing them, lobbying them, meeting with them, holding hearings, being part of such hearings, no less any means of holding them directly, even indirectly accountable....

The RUC in these guys and many other very knowledgeable people's opinions (mine too for the most part) is that it may be the one most forceful and influencial power that has brought American healthcare to the brink of destruction and doom. It has set up the stage for our Way Too Many Specialists and not nearly enough preventive and pro-active primary care, with costly referals and overwhelmed hurried, no influence primaries.... And we all know that this same Fee Schedule is used about 95% of the time to then set the standards and fees brought forth and forced upon us by the insurance industry as well...

It amazes me that the insurance industry has gone along with this so blindly as opposed to doing what would be in their own best interest as to pay Primaries and help them be viable survive flurrish and by using more and helping to employee and get more primaries into such residencies increase their numbers keep the ER visits and referals Down enough to actually save them some serious cash.... all while paying those of us on the primary care side something closer to what we're really worth both in terms of health and improved outcomes as well as in long term savings....

Out of all the healthcare dollars we spend primary care makes up only %5 of all of those dollars consumed.... I forget what specialty care is but I'm thinking about 7-10% because I swear the number for all doctors paid was somewhere around 12% or more but not far from there, so clearly docs in general are NOT the problem like supposedly Labor is the largest costs in Most Industries... But not when it comes to docs themselves....

And never forget that the insurance carriers themselves who really are a Zero Sum Game, NO real Measureable ROI whatsoever.... Increase the costs to us and many others too with Prior Auths and worsened outcomes, deaths, really measureable deaths from denial and lack of access to healthcare..... Add some of the most costs to our consumptions of healthcare spending at about at Least 25% and I seem to remember at least some years ago, some more progressive orgs had them at perhaps as as high as 33% of money spent... and we all know that most countries and our own once you stop monkeying around like they do, can bring those cost down to anywhere from between 5% and 8% of all monies spent.... Gee doesn't that sound like what Docs actually cost???? What if we fired those bozos finally and increased primary care spending and fees by about 50 to 100% and watch the access increase thru the roof, more and more docs would choose the field, less care would be divided, less expensive referrals, less expensive ER, Prompt Care and other kinds of no continuity and preventive progressive positive care.... and Docs would be somewhat happy and positive about their profession and their jobs again leading to actual measureable increases in positive outcomes.... Burnt out docs delivery crumby care and that is a fact, but that is not their fault, it is the systems lead by the carriers and the AMA's RUC.... F'ck the RUC I say....

Paul

For our Dermatology office we always do a biopsy first, those are coded as benign since we must only code to the level of specificity and the reimbursement is the same regardless of diag. for the biopsy. The surgical removal is always set for a later time, allowing for an accurate diagnosis to be used. The only exception to this is in the case of a suspected malignant melanoma, in which case we generally will remove immediately and just hold that bill until the pathology is returned.

The procedures are the same whether removing a benign or a malignant lesion, however the risk factors between the two vary greatly, hence the higher reimbursement for malignant removal. Just FYI