Coding the removal of lesions is determined by the disease process taking place in the tissue removed. The removals of benign lesions are described by codes separate from the code sets used to describe the removal of malignant lesions. Often, a dermatologist does not know if a particular lesion is benign or malignant. He or she may have their suspicions, but the definitive nature of neoplasia is something that can only be determined by examination under a microscope. This is why dermatologists submit the lesions they remove for pathologist review.
A pathology report contains both a gross and microscopic description of the tissue submitted, as well as a diagnosis rendered by a licensed physician who specializes in pathology. A lesion is embedded in a paraffin block and sliced into thin sections. Then it is stained to provide greater visibility of the structure of cells under a microscope. Beyond the hematoxylin and eosin stains that are routine for every preparation, special stains may be ordered on separate slides to identify microorganisms, cellular contents, or immunohistochemical reactions in the cells.
None of these things are routinely performed in a dermatology office. The truth is, a dermatologist cannot be sure of what was removed until after a pathologist has issued his or her report. For this reason, many dermatologists wait until they receive the pathology report before coding and billing a lesion removal.
Just as diagnosis codes are not assigned unless they are specifically documented in the medical record, lesion removal codes should not be assigned on the basis of suspicion. An ironclad rule of diagnosis coding in the outpatient setting is that “rule-out” conditions are not coded until they are ruled in. Without a definitive diagnosis, only the symptoms are coded.
Procedures do not need to be coded and billed immediately after they are performed. Most dermatology practices will wait for a definitive pathologic diagnosis before assembling an outpatient healthcare claim for reimbursement. This is an acceptable industry practice.
CMS and most private health insurers require that coding accurately reflects the information on hand when the codes are assigned. Healthcare claims are not only used to provide reasonable and customary payment for provided services. They are also used by statisticians and medical scientists as raw data to track trends in the occurrence of diseases and the procedures performed to treat those diseases. These statisticians rely on granularity of data and information of the utmost specificity. Reporting neoplasms of uncertain behavior and charging for biopsies that do not take into account the excision of a malignant tumor does not serve anyone well.
By waiting for the pathology report before assigning codes and billing for what was removed, outpatient dermatology practices improve the accuracy of their claims, increase available reimbursement, and provide quantitative data for the healthcare delivery system as a whole.
The majority of specimens submitted by pathologists who specialize in dermatological conditions fall under two codes defined by CPT. They can be 88304, Skin, cyst, tag, or debridement, or 88305, Skin, other than cyst, tag, debridement, plastic repair. While pathology coding is not the concern of a dermatology practice, a dermatologist should have a good idea of what is a cyst, tag or debridement of skin tissue, and what may not be. There is no reason to delay billing for the removal of actinic keratoses or the removal of skin tags, or the removal of necrotic wound tissue.
All of these things may be submitted for pathologist review as sound medical practice. In the interest of timely cash flow and efficient back office operations, when the clinical evidence is overwhelming, there is no reason not to code and bill something like a sebaceous cyst excision as quickly as possible. When there is a doubt, and a suspected condition needs to be ruled out, then waiting for the pathology report prior to assembling a clean healthcare claim is the right thing to do in order to ensure accurate coding.
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