Webinar Q&A From Auditing Dermatology Records Webinar - 5/1/2018
These questions have been answered by the webinar presenter, Kelley Larkins, CPMA, CPC
1) Do we code a premalignant diagnosis as benign or malignant for an excision?
Absent a path report showing malignant, I believe you should code benign. That said, we know in coding, things are often not that black and white. If the attendee has a specific example, please feel free to forward me the exact scenario and I’d be happy to weigh in more specifically. (my direct contact info is on the last slide)
2) When size is not adequately documented, is it better to select the code for the smallest lesion listed, or use the path report measurements? Or should the provider be queried for an accurate measurement? Thank you.
If the provider can provide the measurements, that would be best (make sure they get those documented). Using the path report measurements might work but I couldn’t say that one would always defer to that since the path measurements could vary. For example, are the path measurements provided by the lab in terms of what they are seeing or is there some mechanism in which the path report has the lesion and margins measurement somehow? I think categorically the answer has to be – if it isn’t properly documented in the note and the provider can’t provide and document that, you will have to defer to the smallest.
3) What documentation is required for 17250 Chemical cauterization of granulation tissue. Typically just a small amount of silver nitrate is used to destroy the lesion and there is not much detail to document. Thank you!
On destructions, I suggest you make sure to document the method of destruction – in this case, “Silver Nitrate applied to lesion” – in this case, it’s that simple. The key detail is what was used for the chemical cauterization.
4) Does Kelley use Inga Elzley references as she has always been Dermatology guru?
I use numerous references – Inga Ellzey is one reference. After consulting the specific carrier coverage policies and or CMS policies I usually research with the AAD next. Another good resource is our EHR vendor. Since it codes based on the way the nurses and providers build the note, they too, have coding experts on hand. I query them as to their logic when a note drives a code that is a departure from what we normally have done. Unless you are new to coding/auditing, you know there are areas that are gray or are subject to interpretation so I generally check all of these resources and usually there are some consistent recommendations that help us formulate a position.
5) How common is it to see a Pathology report identify the procedure performed by the dermatologist differently than that actually documented by said Dermatologist? For example, Dermatologist submits code for excision while path report describes a specimen from a shave biopsy.
I believe the two should agree for clear documentation purposes. It isn’t very common in our practice because we have a pathology module within our EHR in which the visit note diagnosis and procedure cross over to the path report so there isn’t any discrepancy. If the lesion is biopsied and destructed it can be held for path results so the proper destruction (malignant or benign) code is documented and billed.
6) Is it necessary (or even "best practice") to hold a biopsy CPT 11100 for pathology when documentation supports D48.5 or D49.2?
It is perfectly acceptable to go ahead and bill the skin biopsy code with the D48.5 or D49.2 diagnosis code. There are also great examples of why to hold for path ( biopsy and destruction performed in same session). If the lesion is biopsied and destructed it can be held for path results so the proper destruction (malignant or benign) code is documented and billed rather than billing the biopsy code.
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